Pinnacle Airlines aircraft incident [Archive]

Airbubba

16th Oct 2004, 06:32

Plane Crashes in Missouri, Killing Pilots

By THE ASSOCIATED PRESS

Published: October 16, 2004

Filed at 12:17 a.m. ET

JEFFERSON CITY, Mo. (AP) -- A small jet crashed in a residential area, killing the only two people aboard, airline officials said Friday. The plane had aborted an earlier scheduled takeoff because of an apparent mechanical problem.

Federal investigators said Friday the regional jet affiliated with Northwest Airlines had aborted a scheduled flight Thursday from Little Rock, Ark., after an indicator light went on for a mechanical system that distributes engine heat throughout the plane. An airplane indicator light typically signifies a problem.

After undergoing maintenance, the 50-seat Pinnacle Airlines plane was being flown without passengers to Minneapolis when its engines failed late Thursday and it crashed into a residential area in Missouri's capital city, killing the two pilots. No residents were hurt.

While noting the previous mechanical problem, National Transportation Safety Board member Carol Carmody said: ``We're not going to speculate on what the causes are'' for the crash.

According to the NTSB, the plane reached 41,000 feet before it stalled and lost power from one engine. At 13,000 feet, the second engine quit. The last contact air traffic controllers had with the plane was at 9,000 feet, when a pilot reported an airport beacon in sight, Carmody said.

The crash site is about two miles from the Jefferson City airport.

Pinnacle Airlines, based in Memphis, Tenn., identified the pilots as Capt. Jesse Rhodes, of Palm Harbor, Fla., and First Officer Peter Cesarz, of Helotes, Texas. Carmody said earlier Friday the pilots' bodies had not been recovered, but that there was ``no doubt'' they had died.

Carmody said NTSB investigators planned to move the engines to an airport hanger Saturday for closer evaluation. Authorities also had recovered the flight data recorder.

Jason Turner, a spokesman for the Jefferson City Fire Department, said the plane appeared to have crashed into ``a garage of some type,'' which was destroyed. The rear of a neighboring house also caught on fire.

At the crash scene, the cockpit was separated by about 70 yards from a large chunk of the fuselage and was so shattered that it could be difficult to recover the plane's instruments, Carmody said.

On Friday, residents marveled at how the plane had managed to miss houses to its left, right and rear. Across the street was an untouched apartment complex.

``Oh boy, it's lucky it didn't hit the houses,'' said Kathryn Hajaved, 72, viewing the damage in daylight for the first time. ``They'll be thanking their God.''

http://www.nytimes.com/aponline/national/AP-Plane-Down.html

Huck

16th Oct 2004, 21:31

[A]n indicator light went on for a mechanical system that distributes engine heat throughout the plane. An airplane indicator light typically signifies a problem.

Bleed leak, perhaps?

typhoonpilot

17th Oct 2004, 15:28

One can't help but wonder what the FAA is going to do about regional airline maintenance after this accident. First two Beech 1900s have fatal accidents and now this. Quality control at regional airline maintenance centers needs a thorough review.

Rest in Peace

Typhoonpilot

Huck

17th Oct 2004, 17:46

Investigators from the National Transportation Safety Bureau released new details in Thursday night's crash of a Northwest Airlink jet that was heading to the Twin Cities.

The NTSB now says that both engines of the 50-seat CRJ failed at the same time while the plane was cruising at an altitude of 41,000 feet. Earlier reports showed the two engines failed at different times.

Investigators say the fact that both engines failed at the same time could indicate a major power failure aboard the plane. Investigators say the pilots glided for nearly 100-miles without power before crashing into a neighborhood in Jefferson City, Missouri. No one on the ground was injured.

5 EYEWITNESS NEWS has also learned that the same jet was taking off from Little Rock, Arkansas earlier Thursday when it had to abort. We now know that flight was headed to the Twin Cities with 40-passengers aboard. Those passengers were placed on another aircraft.

The pilots were flying the jet to the Twin Cities Thursday night, where it would have gone back into service for flights out of Minnesota. The pilot and co-pilot were killed in the crash. The investigation into what caused the crash continues.

ferrydude

17th Oct 2004, 18:23

And what makes you think that regional airline maintenance is any different than major airline maintenance?

Squawk7777

17th Oct 2004, 22:30

Quality control at regional airline maintenance centers needs a thorough review.

You can't be serious ...

Are the CRJs' engines FADEC controlled? Wasn't there an emergency AD a few months/years ago either on the regional jet or on the corporate version - the challenger - regarding fuel pumps?

Rumour has it that the captain was an ex-Waterskier.

7 7 7 7

wrenchbender

18th Oct 2004, 03:44

This CRJ model is not FADEC equipped.

Oilhead

18th Oct 2004, 15:02

Wow - why would one lose both engines at high (?41k?)altitude?

Fuel starvation? Icing related - seems too high to have icing issues - airflow/oxygen issues maybe!

This will be a very interesting investigation...sadly

:(

Willie Everlearn

18th Oct 2004, 16:37

Contaminated fuel?:confused:

ahmedette

18th Oct 2004, 16:43

....or no fuel ?? :uhoh:

Instant Hooligan

19th Oct 2004, 04:16

The CRJ200 is not FADEC controlled, there was a bulletin out a few years ago if I remember correctly about the oil pumps not being to good at high altitude, FL370 and above. causing "gulping" in the oil system. Leading to low oil pressure warnings which resulted in the crews shutting down the offending engine. A descent to lower altitude usually cured the problem.
The CRJ700 is FADEC controlled.
RIP.

Willie Everlearn

19th Oct 2004, 11:24

Absolutely hilarious!

Where did you get that theory??

The CF 34 has an engine driven pump.

The memory items for low oil press is to reduce thrust and observe the result.

:uhoh:

eng123

19th Oct 2004, 11:47

Cant believe the oil pump theory either.The pumps are driven by the gearbox and altitude has no effect on their operation.
Someone earlier said about bleed problems.There are no customer bleed issues that would result in engine failure ever. However an engine bleed issue could result in an engine failure at the right [wrong?] time but for it to be a contributary factor to this accident could surely be ruled out as there would have had to be two separate problems,one in each engine,to have had this result.
There are not too many issues to think about other than fuel starvation/contamination that would effect two engines in cruise surely?

lomapaseo

19th Oct 2004, 12:41

Re: the oil pump story. why don't we just ask if somebody has access to the SBs attached to this engine model for support or understanding?

Re: the bleed theory. Yes it can affect an engines health at high altitude, but again one needs access to SBs vs maintenance on this aircraft to see if the bleed system is likely to affect both engines at the same time?

There is no use in filling in potential causes before an attempt is made to gather supporting facts.

Willie Everlearn

19th Oct 2004, 16:06

The subject aircraft had a low speed RTO earlier in the morning due to a bleed air WARNING in one engine.
It was dealt with in accordance to the AMM, MEL and dispatched as Serviceable.

I have no reason to suspect air bleed in one engine would cause a double engine failure at FL410. Do you?

Anyone familiar with the CRJ probably discounts the bleed air and oil pump theories as not plausible causes.

The most credible speculative theory at this stage of the game, seems to be fuel. I personally don't believe for an instant this aircraft didn't have the required dispatch fuel, so therefore, IMHO, it didn't run out of gas. That leaves me to suspect fuel contamination. I appreciate the fact that I'm still speculating without the benefit of facts.

Neither engine re-lit on descent. I imagine the crew got in a couple of attempts. My guess is that if it wasn't fuel, at least one of the two engines had a very high probability of starting.

No further information has come out for public consumption. But one thing is for sure, something catastrophic happened Thursday night.

My heartfelt condolences to those who knew this crew and their families.

:(

West Coast

19th Oct 2004, 16:35

From a US RJ operator to its crews:

GE has found problems with their improved scavenge pump. Oil gulping may occur when engine is operated at high altitudes (above 370). After prolonged gulping, the oil will begin to foam and then a loss of oil pressure will follow. There is no actual loss of quantity. XXX has had five (5) such events. In three (3) cases, the crew chose not to shut down an engine, but descended to a lower altitude where the foaming stopped and oil pressure returned to normal state. In two (2) cases, the crew chose to shutdown the engine. All crews made the correct decision.

My edit with the XXX to keep the operator anonymous.

"Cant believe the oil pump theory either. The pumps are driven by the gearbox and altitude has no effect on their operation"

"Absolutely hilarious!

Where did you get that theory??

The CF 34 has an engine driven pump"

Be careful

Willie Everlearn

20th Oct 2004, 10:42

West Coast

Thanks.

Very interesting.
I've heard of the oil 'foaming' but the rest is rather suspect.
How does 'gulping' occur? That's a new one to me.

Not wishing to 'eat crow', I'll get back to you on this.
I'll go through my GE Flight Crew bulletins on the CF34 and let you know what I find.

Willie
(FAA ATPL CL65)

SeniorDispatcher

20th Oct 2004, 21:46

Updated info from NTSB....

************************************************************
NTSB ADVISORY
************************************************************

National Transportation Safety Board
Washington, DC 20594

October 20, 2004

************************************************************

UPDATE ON PINNACLE AIRLINES CRASH IN JEFFERSON CITY,
MISSOURI

************************************************************

Washington, D.C. -- The National Transportation Safety Board
today released the following update on its investigation of
the October 14, 2004 crash of Pinnacle Airlines flight 3701
in a residential area in Jefferson City, Missouri, about
three miles south of the Jefferson City, Missouri, airport.
The crash resulted in the deaths of the two crewmen. The
airplane was destroyed by the impact forces and a post crash
fire. There were no passengers onboard, nor were there any
injuries on the ground.

On October 14, 2004, the aircraft departed Little Rock,
Arkansas about 9:21 p.m. (CDT), on a repositioning flight
en-route to Minneapolis-St. Paul, Minnesota.

Air Traffic Control
At about 9:43 p.m., the flight crew checked in with Kansas
City Air Route Traffic Control Center (ARTCC) and indicated
that they were climbing to 41,000 feet. At approximately
9:52 p.m., the flight crew acknowledged that they were at
41,000 feet. At about 9:54 p.m., the flight crew asked for
a lower altitude. At about 9:55 p.m. the flight crew
declared an emergency. At about 9:59 p.m. the flight crew
requested an altitude of 13,000 feet. At about 10:03 p.m.,
the flight crew reported that they had experienced an engine
failure at 41,000. At 10:08 p.m., the flight crew stated
that they had a double engine failure and that they wanted a
direct route to any airport (According to the Flight Data
Recorder both engines stopped operating almost
simultaneously at 41,000 feet.) Kansas City ARTCC directed
the flight to Jefferson City Missouri Airport. At about
10:13 p.m., the flight crew stated that they had the runway
approach end in sight. The last radar contact for the
flight was at 900 feet above ground. The plane crashed at
about 10:15 p.m.

Maintenance
On October 14, the day of the accident, the airplane
underwent maintenance to replace the 14th stage bleed air-
sensing loop on the right engine. During a scheduled 7:45
a.m. departure from Little Rock, Arkansas to Minneapolis
St.-Paul, Missouri, an Indicating Crew Alerting System
(ICAS) message stating "R 14th duct" occurred during take-
off and the flight crew (not the accident crew) aborted the
take-off and returned to the gate. The 21 passengers were
deplaned. The airplane never left the ground.
Two mechanics from Pinnacle's Memphis, Tennessee facility
did the repair. During a Safety Board interview on
Saturday, the mechanics stated that they only replaced the
No. 2 (right) engine's 14th stage bleed air sensing loop.
The mechanics completed the repair and tested the system.
The aircraft was released for flight. On-scene evidence
confirms that the repair was done in accordance with the
Aircraft Maintenance Manual.

The aircraft was equipped with two GE CF34-3B1 engines. The
right engine had accumulated 2,303 hours and 1,971 cycles
since new. It was installed new on the aircraft on October
23, 2003. The left hand engine had 8,856 hours and 8,480
cycles since new. It was removed from another aircraft on
October 30, 2003 and installed on the accident aircraft on
April 6, 2004. Maintenance records indicate that during an
A4 check on June 9, 2004, the left engine igniters were
replaced. During an A5 check on August 18, 2004, the right
engine igniters were replaced. The most recent check was
the A5 check performed on August 18, 2004.

Operations
The Operations group traveled to Memphis to interview pilots
who had flown with the two crew members and to interview
some of the airlines training personnel and managers. There
are 10 to 12 interviews scheduled.

Wreckage
On-scene examination of the wreckage shows there was no sign
of an in-flight fire on the structure of the aircraft. The
airplane was found inverted and separated in several
sections. All four major flight surfaces were found at the
main wreckage site. The cockpit area was severely damaged
by the post crash fire.

During the Safety Board's examination of the engines, it was
noted that there was some thermal damage to the No. 2 engine
and that will be further looked at during a teardown in
Lynn, Mass. The engines will be shipped out today.

The wreckage is being shipped to Rantoul, Kansas.

Since the accident, the operator, Pinnacle Airlines, has
placed a new company altitude restriction on the flight
ceiling for their CL600-2B19s of 37,000 feet.

Parties to the investigation are Pinnacle Airlines, Federal
Aviation Administration, Air Line Pilot's Association,
National Air Traffic Controller's Association, and General
Electric (GE). The Transportation Safety Board of Canada
has sent an accredited representative along with technical
advisors from Transport Canada, the agency that certified
the aircraft, and Bombardier Aerospace, the manufacture of
the aircraft.

###

West Coast

20th Oct 2004, 23:42

Perhaps I have missed something in the article so send me where I need to go, but it doesn't matter if ATC denied descent clearance with both engine gone.

Many years ago at another employer I was part of an acceptance crew for a CRJ. One of the pre delivery checks was to turn off the packs up at higher altitudes and check the cabin rate of climb. It was no where near rapid as one might think. Exact numbers escape me but it was a lot less than I would have thought. There are cabin pressure cutions at 8500 CPA I believe and a warning message at 10,000 CPA. Plenty of warnings to don masks if you lose pressurization.

Instant Hooligan

21st Oct 2004, 01:10

Thanks West Coast I knew i had read the info correctly but could not find the memo to post.

Ignition Override

21st Oct 2004, 04:43

There is suspicion among CRJ crews at Skywest, that the fueler at Little Rock Airport (LIT) mistakenly put Avgas into the plane, instead of Jet A. Could a "Jet A" truck mistakenly have Avgas onboard? We rode in the same hotel van in Saginaw (MBS), Michigan.

Others wonder whether there was water in whichever fuel was pumped into the plane. Another word is that the Pinnacle CRJs' max ceiling is now several Flight Levels lower than before the tragedy.

A Pinnacle pilot who jumpseated with us told me that one of the deceased pilots was a friend, and was married with one child, and another "on the way". The worst type of tragedy for a young family and the other various family members.

Willie Everlearn

21st Oct 2004, 10:42

13,000 is for the engine relight activity.

It's unlikely, as West Coast says, pressurization was a problem initially.

WEST COAST
I've been checking with contacts about the 'frothing issue'.
If I've got it right, this WAS a problem as you've stated. It seems to not be a reason for engine failure as the system is aerated if the oil bubbles.

AVGAS?? Possibly.

Maybe fuel without a freezing additive. Who knows?

:confused:

Mr_Good_Looking

21st Oct 2004, 11:17

Ignoring the reasons for the engine failures for a moment, from 41,000ft and a 20 minute glide, am I the only one who is a little surprised the outcome is as it has been.

Would you have expected them to get it into the airfield (any airfield in fact, previous posts mentioned it travelled over 100 miles) under such circumstances?

hec7or

21st Oct 2004, 11:52

my personal experience as a tre on the crj is that it is very unforgiving during low speed and low altitude manoeuvring, with double engine failures in the sim frequently resulting in low altitude loss of control.

the aircraft has no leading edge high lift augmentation and almost imperceptible pre stall buffet especially with the gear down and possible inadvertent speedbrake deployment.

these guys were extremely unlucky to be faced with a nightmare situation.

West Coast

21st Oct 2004, 16:20

Willie

I am walking a fine line here as I don't want to speculate on the reasons for the crash. I am talking systems and staying away from probable cause.
That said I don't know if the oil frothing is a potential area or not. Professionals in that field will determine that. My earlier response about the oil pumps was strictly to enlighten pilots that there has been problems with the oil system at higher altitudes.

As far as a freezing additive, to my memory there is no manufacturer requirements for Prist type additives as the aircraft is equipped with a fuel heaters via a heat exchanger with the number 3 hyd system. There are also a caution message for low fuel temperatures that sounds off somewhere near + 5C.

Bulk fuel is another story with much lower temps possible.

411A

22nd Oct 2004, 04:44

Just why would these guys take the aeroplane to FL410 anyway?
What was the cruise buffet onset boundary at this altitude and the acft weight in question?

Was it really necessary to go that high...or was it a case of guys just wanting to get there (height) because they don't see this in normal revenue service.

Early jet transport pilots found out soon enough that higher is not always better.
Perhaps junior jet guys never bothered to learn...from others misfortunes.

surplus1

22nd Oct 2004, 04:44

I've been reading a lot about this accident on another forum in the US. As usual, many pilots that operate this aircraft a commenting.

Must say I'm alarmed at what appears to be a remarkable lack of technical knowledge of the aircraft's systems and procedures on the part of pilots that claim to work in it.

Willie Everlearn

22nd Oct 2004, 10:39

I once had a student with several thousand hours accept 41 without checking its operational acceptability.
When I questioned him about it he told me the aircraft was certified to 41 so we could accept the clearance.

You'd be surprised at the lack of technical knowledge AND aerodynamic knowledge of most new to jet flying and to the RJ.

But, IMHO, the greatest portion of very highly experienced Regional Airline pilots is turbo-prop experience flown at the mid altitudes. That's not to put them down it's to point out why this lack of knowledge needs to be filled by instruction.
I'm afraid, like many things in aviation, there seems to be far too much taken for granted.

TCS

Thanks ever so much for the excellent site on Controlling Oil Aeration and Foam to learn something.

much appreciated
:ok:

ironbutt57

22nd Oct 2004, 11:25

How can we comment on the FL that the pilot chose to operate at without knowing the reasons he chose to do so? Company pressures, post maintenance requirements, and do we know in fact this crew was low on jet experience? What was the optimum FL for this aircraft at the existing weight/flt plan speed? Many good reasons may exist for operating at a rather high FL,...or they may not...theorize...yes...criticise...not yet!

Oilhead

23rd Oct 2004, 21:28

411A and Willie raise some possibly highly valid points.

I would not be surprised to hear that high altitiude training at this airline is under intense scrutiny by NTSB/FAA in light of the nearly instant 37K limitation imposed by this airline on their crews. If there was an immediate technical concern to cause that limitation, would there not be a general warning issued to all operators while the investigation continued? This limitation appears to be only related to the subject airline.

The apparent lack of a successful airborne relight in the several minutes available is also most odd.

High altitude performance and training will be under the microscope. The highly unscientific poll results I have done on RJ friends since this accident - NOONE has been up there in this type of plane.

russellackland

24th Oct 2004, 06:02

All,

I flew at this airline for 2 months as a new FO on the CRJ in 2003. I was not impressed by several things [pay/upgrade time] and found another job to occupy my NWA furlough time. It is a sad event, but this little airline grew (is growing) too quickly and there are some deficiencies. A lack of high altitude (coffin corner) type training is but one example of a very poor ground school program. I questioned some of the "check airmen's" understanding of aerodynamics, but when push came to shove, agreed to their mis-understandings to get the check-ride over with. One of the ground school instructors at Pinnacle was ramper with "ZERO" flight training who once argued with me about the CRJ landing gear "trucks." Can't say that pilot error had anything to do with this accident, but from my personal experience, I wouldn't be surprised if there were shortcomings in this accident attributed to Pinnacle's training program.

dudduddud

24th Oct 2004, 10:18

Non-crj200 pilot here and pure speculation at this stage but it seems the ultimate cause of the crash was not the double engine failure at altitude (which would be alleviated with a max cert alt of FL370) but by the low speed characteristics.
KAIZ was a much closer airfield with full ils available. We need to check the decent profile but the crew (RIP) either encounted unexpected WS or lost control at low speed.

Two questions for CRJ200 pilots:
1) What low speed warning indicators are available on the CRJ200?
2) Do you think they are sufficient?

Huck

24th Oct 2004, 15:02

I flew the CRJ for 1000 hours in 1997-98. Two things pop to mind after reading what we know so far:

1. The CRJ lands at 1.5 VStall, and it's for a reason. Memory fails me, but it seems more than one was lost during flight test in the slow-speed regime. Of course, the 70 seater here had leading edge devices, didn't it?

2. I went through one month of training at Bombardier in Montreal. In 10 sim rides of 4 hours each I manipulated the controls maybe a total of one hour. Empshasis was squarely on automation, and if you told them you wanted to learn to hand-fly it was if you had uttered a profanity in church. That said - most line pilots quickly shed that insanity and learned to put the actual aircraft through its paces without George.

Ignition Override

25th Oct 2004, 04:30

I saw more pilots hand-fly the 757 to FL 230 than a steam-gauge plane to 14,000'. Maybe the higher thrust/weight ratio with hydraulic controls is more rewarding.

Airlines which hire experienced pilots have little reason to be afraid of pilots hand-flying the plane. In a country (even our neighbor Canada?) where pilots have very limited experience, then maybe there is concern for their skills without automation to always save the day. Were not many modern airplanes designed to help new pilots avoid having to either hand-fly or handle a basic autopilot (the older type) with just an altitude-hold feature, while trying to navigate?:confused:

West Coast

25th Oct 2004, 06:51

Flew the RJ for 4 years at SkyWest.

Low speed cues are a green line on the airspeed tape at 1.27 VS.

Agree with Huck about the emphasis on use of automation. On line most guys hand flew it to the flight levels.

I have to disagree about the old timers bagging on the RJ pilots of today not having adequate high altitude training. One must only look at the numbers. Thousands of legs per year in RJ's over the past decade and no airline fatalities on the aircraft from lack of high altitude knowledge that I am aware of, supposition only for the Pinnacle accident. I suppose one could make comparisons from 50's era pilots transitioning from prop planes to jets and regional pilots transitioning from props to jets. Not quite an equal measurement but the learning curve for the old timers was a helluva lot deadlier than for the regional guys making the leap.

boxmover

25th Oct 2004, 19:47

True

BUT climbing that curve in the 50s and 60s killed a hell of a lot of our pax

Red Mud

25th Oct 2004, 20:12

FYI the CRJ2 V Ref is 1.25 Vs. Also, autopilot emphasis seems to be a need to alleviate the pressure on the new guys transitioning to their first jet. However, nothing precludes a line guy from hand flying a departure or arrival.

hec7or

25th Oct 2004, 20:52

are we talking handflying with the fd or handflying raw data, the former puts a huge load on the non handling pilot who has to programme the fd for the handling pilot, do the checklists and handle the rt and do any paperwork the company may require

411A

25th Oct 2004, 21:40

Program your own FD, hec7or, instead of relying on the non-handling pilot.
FYI, this was done for many years on the first generation jet transports (B707's/DC8's) and was not a particular problem.
Twist/push the concerned knob for the desired result.

Are you suggesting that 'modern' guys can't do this very simple act?

If so, just maybe they don't belong at the pointy end.

Automation is all fine and dandy, but when guys forget basic skills, they are indeed up the creek without a paddle.

Why am I not surprised?:{ :{

Roidelstein

26th Oct 2004, 08:11

It's nothing to do with 'modern' guys being unable to do this simple act. Some companies have an SOP saying PNF must program the FD.

Pontious

26th Oct 2004, 15:46

Roidelstein

Don't rise to 411A's bait. His track record of glib remarks speaks for itself. He's just a bitter and twisted old man who's days with 'a major' or probably over.

:ok:

ironbutt57

26th Oct 2004, 15:56

Think 411A might have a valid point, as does Roidelstein.....the PNF can very quickly become overloaded while the PF enhances his/her handling skills...common sense has to be the determining factor when to hand fly, and when to use the automatics....and of course strict compliance with SOP's is a given....in a busy crowded airspace area..automatics also free up both crewmmbers to maintain their outside vigilance as well...

Willie Everlearn

27th Oct 2004, 11:06

Gentlemen,
Reading through some of these posts, I have to say for me, they translate into not much more than 'pilot ego'.

The RJ is a sophisticated aeroplane with sophisticated avionics. There are issues with this aircraft as far as ergonomics is concerned, no question.
But it is, like many 'glass cockpit' aircraft out there, designed to make the maximum use of automation.

As a TRI on the RJ I have to say from my personal instructing experience, many RJ newbies lack the 'jet' skills required to fly this aircraft. Or, they simply don't have a complete understanding of jet flying and associated aerodynamics. (My apology for the generalization)
I am not saying they won't/don't acquire those skills over time.

Sticking to automation, the use of manual flight is for any pilot at anytime. With or without FD guidance. Manual skills need to be maintained. For sure. Flight mode and flight mode awareness are paramount with any of the glass airplanes out there and it is incumbant upon anyone flying the RJ or any other glass airplane to be completley familiar and conversant with autoflight and associated FMAs.
I still see the Dash 8, EMB, Saab 340 types jump into the RJ and want to fly attitude with no FD, or constantly SYNC the FD while not fully conversant with the technology.

My recommendation would be to learn and master the auto-magic first, before focusing on hand flying. Especially if you are on an initial sim course. Oh yes, and one more thing, make sure you time its use so you don't overload the PNF. Overloading the PNF is something the Regional pilots are very good at doing.

What part any of this has played in this recent event remains to be seen.

I have flown the RJ at FL410 and as long as it's flown by the numbers, guess what? It's a non-event. :ok:

fdgolf

27th Oct 2004, 17:14

hec7or

a bit off topic, but my opinion wrt paperwork is that it should only be done when a/p is engaged (other than operational flight plan checks). If a/p does not work, do the paperwork upon arrival on the ground.

Cheers

give me an axe

27th Oct 2004, 21:03

I am suprised that they were able to get a CRj 200 upto FL410 - i have frequently operated positioning flights of this type and even with no pax on board these aircraft will struggle to get upto FL350 - esp an aircraft that has had this number of hours on the engines.

now the 700 , thats a different kettle of fish, more like a love sick angel - it'll get you upto FL410 even with reasonable pax number.

fdgolf

27th Oct 2004, 23:03

give me an axe, I agree the aircraft might srtuggle to get to FL350 during summer, but for a positional flight it is no trouble whatsoever to reach it. During the rest of the year the aircraft appreciates the cooler air and climbs in a better mood...

;)

lead zeppelin

28th Oct 2004, 17:49

Pinnacle Airlines Reports Third Quarter Earnings of $12.6 Million

Pinnacle Airlines Corp. today reported third quarter operating revenue of $168.1 million, resulting in revenue growth over the comparable period in 2003 of 40 percent. The company produced operating income of $18.5 million, an operating margin of 11.0 percent, and net income of $12.6 million.

Operating revenue for the nine months ended September 30, 2004 was $454.1 million, resulting in revenue growth over the comparable period in 2003 of 38 percent. The company produced operating income of $49.8 million, an operating margin of 11.0 percent, and net income of $30.4 million.

The company's capacity in available seat miles (ASMs) increased by 58 percent, block hours increased by 56 percent, and cycles increased by 42 percent during the three months ended September 30, 2004, compared to the same period in 2003.

Squawk7777

29th Oct 2004, 00:29

Rumour mill has it that there were approximately 250 switch movements from the time of the engine flameout(s) to impact.

give me an axe

29th Oct 2004, 09:19

Squwak 7777 - and what are you implying ?? I think you'll find if you were in a sphincter moving situation you to would be presssing the engine start buttons as often as you could.......

lomapaseo

29th Oct 2004, 12:48

Squwak 7777 - and what are you implying ?? I think you'll find if you were in a sphincter moving situation you to would be presssing the engine start buttons as often as you could.......

Axe/Squwak

I don't understand the 250 either, relative to engine start.

Could you outline for me what switches would be toggled for a start attempt and restart attempt.

Oilhead

29th Oct 2004, 14:17

What is the relight envelope for this plane - some engines won't start until you are down in twenties or lower at a particular speed envelope? The implication is if you lose both and follow Flight Manual/QRH guidance - you may have to sit on your hands for a few minutes while the plane gets down to a directed altitude and airspeed.

Also - does this plane have an electronic checklist - eg like the Airbus ECAM system that will automatically bring up relevant engine failure/relight checklist etc.

give me an axe

29th Oct 2004, 14:58

There is no electronic reference manual, this is directly from the QRH

DOUBLE ENGINE FAILURE EMER 1-5 REV55 Jul 13/01

1 CONT IGNITION................ON

if engines continue to run down

2 THRUST LEVERS (BOTH).........SHUTOFF
3 ADG manual deploy handle...PULL

when ADG power is est
4 STAB TRIM CH 2............ENGAGE
5 target airspeed..............ESTABLISH

FLT LEVEL TARGET AIRSPEED
ABOVE 340 0.7 MACH
BELOW 340 240 KIAS

maintain airspeed until ready to restart engines

6 APU (BELOW 30,000 FT)..................START
7 APU GEN (if APU avail).......................ON

check/ reset barometric altimeter setting, altitude preselector, V-speeds and speed bug settings after ADG deployment or APU generator switching

windmilling relight possible (requires airspeed of not less than 300 KIAS)

YES

(from 21,000 feet and below)

8 Relight using windmilling procedure
(see page EMERG 1-6).......................ACOMPLISH
Maintain 240 KIAS until ready to initiate windmill start

NO

(from 13,000 feet and below)

8 Relight using APU Bleed Air Procedure
(see page EMERG 1-8).......................ACOMPLISH
Maintain between 190 KIAS(23,000 kg - 51,000 lb) and 170 KIAS(16,000 kg - 36,000 lb)

Squawk7777

30th Oct 2004, 02:23

I'm not implying anything. I just posted what I heard. This is a rumour bb after all.

7 7 7 7

Ignition Override

2nd Nov 2004, 03:33

How long had they been on continuous duty?

411A

2nd Nov 2004, 04:35

Oh, I can hear it now...they were tired, so the engines quit.:rolleyes: :rolleyes:

Squawk7777

11th Nov 2004, 15:33

Second NTSB Update On The Pinnacle Airlines Crash

Aircraft Apparently Entered Stall At 41,000 Feet
The National Transportation Safety Board Wednesday released the following
update on its investigation of the October 14, 2004 crash of Pinnacle
Airlines flight 3701 in a residential area in Jefferson City (MO). The two
crewmembers, who were the only occupants on board, were killed, and impact
forces and a postcrash fire destroyed the airplane. There were no injuries
on the ground. The on-scene portion of the investigation finished on October
20, 2004.

The two GE CF34-3B1 engines were shipped to a General Electric Aircraft
Engine facility in Lynn, Massachusetts for detailed examination. The
examination found that the cores of both engines were free to rotate and
there was no indication of any pre-existing problems that would have led to
the accident.

The flight data recorder (FDR) data indicate that while the airplane was at
41,000 feet, the stick shaker and stick pusher activated several times
before the airplane entered an aerodynamic stall. Almost simultaneously,
both engines shut down. The air-driven generator was automatically deployed
and supplied the backup alternating current power to the airplane.

According to the emergency checklist for a dual engine failure, there are
two ways to restart or relight the engines. One option is to use a windmill
restart, which requires at least 300 knots indicated airspeed and the core
of the engine to be either 12 percent rpm above 15,000 feet or 9 percent rpm
below 15,000 feet. The FDR data show that the computed airspeed did not get
above 300 knots and that there was no measured rotation of the engine core.

The second option is to use auxiliary power unit (APU) bleed air, which has
to be accomplished at 13,000 feet or below. The target best glide speed
depends on the weight of the aircraft and is either 190 knots indicated
airspeed or 170 knots indicated airspeed. The FDR data indicate that the APU
was on after the aerodynamic stall and that the airspeed was sufficient for
an APU start. The FDR and CVR indicated that the flight crew tried to start
the engines several times but were unsuccessful.

The operations group is still conducting interviews and developing the
72-hour history for the flight crew. The operations group has scheduled
interviews with the Federal Aviation Administration principal operations
inspector and several managers for the operator. The systems, powerplants,
and aircraft performance will visit the airplane manufacturer.

FMI: www.ntsb.gov

411A

12th Nov 2004, 00:52

Hmmm, well if the previous is factual, perhaps the junior jet guys need a bit of training about high altitude aerodynamics, and especially cruise buffet onset.
Why am I not surprised....:uhoh: :uhoh:

In years gone past, these are some of the same problems faced by pilots of 707's and DC8's.
I would have hoped that these earlier incidents would be well known...guess not.:sad:

gashcan

12th Nov 2004, 07:35

If I understand him right, 411A reckons that the pilots were either negligent in allowing a high (or low) speed upset or ignorant of the possibility of such an event. Therefore they are directly attributable for the incident, which apparently occurred with an associated engine(s) failure.

Bit patronising and arrogant of him to be so presumptuous I think - or else he knows exactly what happened.

You weren't there, you don't know why the engines failed or why the aircraft was upset, so have a bit of humility, get off the guy's backs and leave it to the NTSB.

There for the grace of God - (possibly, possibly not) - go you.

Squawk7777

12th Nov 2004, 17:34

I partly agree with 411A on this issue. Some regional airlines' training is very basic in certain subjects to say the least. Looking back at my CAA ground school days regarding this issue, I don't recall anything about high- altitude aerodynamics either.

7 7 7 7

411A

12th Nov 2004, 23:15

Yes, gashcan, I am surprised that the junior jet guys have not learned lessons long ago forgotten.

Lets be clear...the aerodynamics of swept wing jet aircraft have not changed all that much, since the old days.

Oh yes, they have all the fancy equipment up front (glass...well designed FMS etc...) but the fact remains that they do not, have all that much difference.
Ignore the basics...crash and burn.

DP Davies said it all in 'Handling The Big Jets' and if you ignore the very basic facts about high altitude flying in these aircraft, you will fail in your attempts at success.

Find an old copy...and learn.

To those that don't (or cannot bother), are prone to making the very same mistakes learned so long ago.

Captain Davies has been gone for a year...very sad for the younger guys.
From Comet to Concorde...he was the best.:ok:

ontrackfor

13th Nov 2004, 13:52

Stall at Dead mans' corner. The plane didn't tumble out of the sky though because the crew made relight attempts. I'd say they regained control soon after the initial event because it seems they made re-light attempts 'on the way down'. If I was in a stall/spin, I'd rather get the attitude sorted before thinking about relight. I still think this incident became fatal (RIP) at low level.

[edited to say i am a non-crj200 pilot]

jonny dangerous

14th Nov 2004, 14:51

I'm not terribly familiar with the CRJ, does it have WING ANTI-ICE capability?

JD

Mad (Flt) Scientist

14th Nov 2004, 20:28

I'm not terribly familiar with the CRJ, does it have WING ANTI-ICE capability?

Yes, it does.

But there's no practical probability of airframe ice at 41,000ft.

CRJ2

15th Nov 2004, 17:06

Does anybody know the weather-situation arround there at the time of the accident?

weasil

15th Nov 2004, 22:54

ntsb said the weather was clear and the temp was ISA +10

Ignition Override

16th Nov 2004, 05:48

Johnny: It is safe to say that all transport-category aircraft have wing and engine anti-ice, plus continuous engine ignition. On a pure jet (turbo/fan-) it consists of heated ducts for the wing leading edge and usually the horizontal tail leading edges, along with electrically-heated pitot-stall, ram air temp. and other probe equipment, plus the windshields, of course.:E This is my symbol for winter flying-cold and frozen evil (if those guys don't de-ice the runways:mad:, when they are supposed to).

Don't laugh-it happens, and planes slide off, even when they touch down in the right zone and on speed, with little crosswind and no tailwind .:uhoh: A guy in my upgrade class years ago turned off the runway just fine and he said "I got no brakes!" . The local yokels (Michigan or Wisconsin) had not sprayed the turn-off areas by the active runway. Thanks to the Check Airman slamming both engines reverse levers wayyyy back into max reverse, they barely stayed on the concrete ( using EPR, not torque). Instead, the engine inspections created quite a delay for the outbound folks :( . Maybe 90+people...

Woops, wrong topic-I guess no lessons can be learned if wrong topic.

Willie Everlearn

16th Nov 2004, 11:18

Just speculating....

...if this aircraft was at roughly 37,000 lb for Takeoff in LIT, then a M0.74 cruise at FL410 ISA was marginally possible.

...IF it was ISA+10 at 41, at roughly 37,000 lb for Takeoff, then a M0.74 cruise at FL410 was NOT possible. (according to the charts)

The crew surely would have participated in a real 'struggle' to climb to 41 during the last couple of thousand feet with all relevant and obvious indications. If SPD mode (CLB .70) was used to milk the last bit of climb out of the aircraft then it would have probably NOT accelerated once level due to CRZ thrust limit's inability to overcome the drag in the thin air and accelerate back to .74. On top of that, they might also have been very, very close to the Vls (stall). At this point it must have been very obvious to the Capt. it was time to descend.

On top of that, ISA+10 at altitude would cause a 2% increase in fuel burn and off optimum by 4 thousand feet would have introduced a further 7% increase in burn. Almost a 10% increase in forecast burn.

I'm wondering why a climb above optimum was even considered outside of any enroute weather? At -57 C, what possibly could have been their reason?
:sad:

jonny dangerous

16th Nov 2004, 12:34

Thanks Ignition, realize now it was a silly question. Have been getting up too early the last week (4:00 am, and I'm on days off!) and the combination of coffee and quiet in the house led my fingers to propel my brain to places it shouldn't have gone.

Mr Willie Everlearn (Betty Wohnt...) your posting doesn't explain the engine failures though. Or did I miss something?

Struggling up to altitude and then deciding to go down is one thing, but losing both engines wasn't part of the agreement.

Over...

JD

Looking at the engine start options, if they wanted a windmilling start the QRH says 240 KIAS until ready then 300 KIAS for the start. Bit of a pickle really as best glide speed might make you glide further (TS 236 to Azores) but the increased was speed needed for windmilling.

I Imagine it cooled off and fogged up until the APU is relit ( below 30,000 from the QRH) and supplying heated air. So a glide of 11,000 feet is commenced at night, waiting for the APU start altitude. Once that's done, its another glide to wait for FL210 to commence the windmilling start. If that doesn't work (imagine the descent rate at 300 knots!), its time to try the APU bleed assissted relight, at 13000 feet.

How does this scenario play out in the simulator, or have I got the sequence of actions messed up? Looks pretty challenging, given the low speed handling characteristics as posted above, and the sense of panic that would be just bubbling inside of both pilots...

JD

Golden Rivit

16th Nov 2004, 16:49

Here is a different slant to what might have occured in this thread. Run this in Google, http://forums.flightinfo.com/showthread.php?t=42858

jonny dangerous

16th Nov 2004, 21:57

Golden Rivet thanks for the thread link. Very unfortunate to see some of the ideas floating around the industry in terms of climb capability and techniques to get there...

JD

Ignition Override

17th Nov 2004, 05:25

I know a guy who has an interview with P. very soon.

Unfortunately, his previous employer often avoided seniority (with solid turbine PIC experience) for upgrades.

Few Cloudy

17th Nov 2004, 08:52

How do the fuel heaters work? - by heat exchanger from one of the hyd. systems?

Is this continuous? Is there a backup if that Hyd System goes u/s?

Willie Everlearn

17th Nov 2004, 11:22

Johnny D

I suspect the NTSB will give us a definitive answer on the double Engine failure. Not me. I've been wondering the very same thing. And you're right, it wasn't part of the deal. My guess is the CF34 itself at high altitude in very thin air. With a high angle of attack to maintain altitude, (another of my assumptions) airflow over the wing might have disturbed the airflow through the engines. However, prior to any aerodynamic stall, you have automatic continuous ignition.
FL410 must be really, really close to the performance limit for this engine anyway. (Watch this space)

Possible scenario: (note: "possible")
The ADG provided ship's power till FL300 following the loss of both generators.
At FL300, the APU could have been started. Power restored. AP engagable. FMS back in business. Cabin Alt still slowly climbing cuz the APU can't provide pressurization above 15.
At 26,000 the aircraft is pitched down to accelerate to 300 KIAS + and at 21,000 the aircraft should be at 300 KIAS when the crew would confirm start parameters, select continuous ignition and start an engine. Depending on crew skill with the QRH, they might not have increased from 240 KIAS to 300 KIAS as stated in the re-light procedure. The core speed of the N2 wouldn't be much above 2 or 3 %, if that. Even at 240 KIAS.
Depending on the tail number of this aircraft, they needed 330-335 KIAS to conduct a windmill start.
Prelim info suggests the aircraft didn't exceed 300 KIAS which would explain their inability to re-start an engine above 13.
You would certainly expect at least one engine to have been re-started using the APU. But then, we don't know how the procedure was followed. Nor do we know how 'excited' the crew might have gotten as they neared low altitude, an airport and uncertainty. All we know is the result.

:sad:

jonny dangerous

17th Nov 2004, 11:34

Yo Willie, sounds like you're current on the CRJ, so a couple of questions...

Does the FMS give you an OPT and MAX altitude? (I assume it does). The link to the other forum's Pinnacle thread, had some interesting techniques for determining cruise altitude capability, some of which seemed to imply the FMS doesn't supply that info.

Is the Autopilot that poor in holding IAS in the climb, in terms of oscillation etc? Some guys on the other forum, actually joked about climbing in VS or pitch mode until stick shaker woke them up...personally from the DH8 upwards, I was taught not to climb in VS, but if its that crappy a ride in Speed mode...

Regarding information from the Primary Flight Display, i.e. low speed buffet, is it accurate and displayed while in clean configuration. A couple of posters stated that the 1.27Vs bug or whatever you call it was only applicable in the landing config?

The other nagging question is altitude capability. If these guys had just fuel and themselves on board, how restrictive would it be to get to FL410. I have to assume that in an airplane certified to that altitude, if they were practically empty, it shouldn't be too tough to get to 410. Thoughts?

Willie Everlearn

17th Nov 2004, 12:21

Few Cloudy

The RJ fuel is fed through a heat exchanger on the engine. It is unlikely the fuel 'geled'.

"IF" these guys suffered an aerodynamic stall then it is also possible the engines flamed out, even with CONT IGN. (Depending upon aircraft attitude, etc)

One possibility is that during an APU in-flight re-light at or below 13,000 the crew didn't get the bleeds transferred to the APU from the engines as stipulated in the QRH. If so, they'd never get an engine started.

Cheers
:{

jonny dangerous

17th Nov 2004, 13:10

Groundskeeper Willie, just read your post on the sequence of events, very plausible. I might add that I might have had my quick donning mask out/possibly on, should we have experienced the double engine failure, at night to boot, even if the QRH didn't call for it...if I had the time (as my world fell apart).

Its certainly possible that a switch gets missed. Either both guys misconfirm a switch due to the stress of the alarm bell filled cockpit (nighttime as it was) or one guy misses it while the other guy is busy flying and talking on radio, looking for a runway somewhere...Then a diagnosis at low altitude that distracts both pilots from the, ahem, purpose of the exercise.

The Air Transat Glide was a piece of cake compared to this...

The AT236 guys had daylight. They knew they had no fuel, so let's not spend a whole bunch of time trying to start it. Let us keep the speed constant at well, greendot? Find land. One choice? Perfect. Certainly it's in manual backup, but it'll do...

The Pinnacle crew, relatively low timed as they were, were facing a multiple of sensory inputs and decisions followed by task completions that in all probability overwhelmed them. In the Air Transat incident, despite whatever brought them there, the Captain had a depth of experience that aided him well, at the end of the day. However, he wasn't tickling several dragons by the tail, as it seems the Pinnacle crew.

At this point I think the 411 guy pipes in...

West Coast

17th Nov 2004, 13:31

"At 26,000 the aircraft is pitched down to accelerate to 300 KIAS + and at 21,000 the aircraft should be at 300 KIAS when the crew would confirm start parameters"

Has the QRH changed to reflect this? When I went through it wasn't laid out as concise as this. It simply told you the min speed was 300 Kts and to be at 21,000. If you didn't have an epiphany or the sim instructor didn't tell you most guys would get to 21,000 and then start accelerating. It took 5000 ft to achieve 300 Kts which meant you were at 16000 feet when you achieved proper speed, eating up part of the start envelope and putting you closer to terrain.

Willie Everlearn

17th Nov 2004, 14:11

J D

Briefly, the Collins FMS doesn’t provide the crew with an ability to check OPT ALT, STEP, or MAX altitude calculations. If you insert an altitude on the PERF INIT page above FL410 you get a message stating UNABLE CRZ ALTITUDE.
How reliable is it?
You tell me. I don’t use it. I look it up.
If the distance to go is insufficient for a climb then it should advise UNABLE CRZ ALTITUDE.
The time to determine your OPTIMUM altitude is during pre-flight. Check the met, winds aloft, weights, routing and flight planned altitude, etc. Based on your calculated weight reaching CRZ, from your OPF, you should confirm your optimum and Max altitude by looking it up in the RJ Manual. At a weight of 40,000 lb or less in ISA conditions the RJ should make FL410 (according to the chart) At ISA + 10 this aircraft would have to be less than 36,000 to maintain FL410 and M .74.
I agree, the RJ “seems” to be a lot more stable in V/S. Personally, I’m not impressed with the Collins AP/FD in the RJ, but that’s what you get.
When you decide to leave optimum altitudes you cost the company $$$. So why would you climb? (Except for the obvious reasons) Like any other aircraft in V/S, the RJ will maintain V/S as selected. The problem has more to do with thrust limit (Engine MAX CLB power setting). The higher we go above optimum the less available thrust output to get us there, so we begin to lose IAS and move toward the stall. Your rate of climb may be good. Unfortunately, KIAS/Mach, isn’t.
Speed mode is affected by temperature and winds aloft while climbing. Therefore, on climb and descent it will tend to be a lot more active in pitch to maintain a constant KIAS.
This is not a put-down, but I find many regional pilots, new to jets and the RJ (sometimes), baffled by this. Most regional pilots are coming from years and years and years of turbo props. (Dash 8, EMB, Saab, Dornier, etc.) so it’s a bit of a surprise. Reading tends to help.

Be careful with FAA customers. “N” registered aircraft have a “green line” mandated by the regulator, which is displayed on the PFD. It is probably correct to say the green line is most accurate during the approach phase. Airbus types would equate it to the “green dot”.
The missing element to your understanding is thrust limit and weight. You have to be light enough to make 41. I don’t think they were light enough and I don’t think it was ISA at 41 either.
I also think they may have tried an APU start at 13 but may have forgotten to configure the bleeds. (Purely speculation on my part)

lomapaseo

17th Nov 2004, 14:28

Just a couple of coments to reinforce what some others have already said.

The engines at altitude are typically operating with reduced stall margin. If you upset the inlet air by a flow separation off the wing they will likely stall, albeit quietly due to high altitude effects. In spite of continuous ignition the engine may not recover with the aircraft also in a stall mode,before they spool down far enough that they can no longer be relit automatically.

The inflight restart specifications after that are very specific and must be met if you are to reliably restart a spooled down engine. Too high an altitude and too little ram air spool up and the restart may not work. Worse yet you are liable to get a hung or hot start and if left unabated you will burn out the turbine and all hope is then lost for even a normal restart at the right conditions.

jonny dangerous

17th Nov 2004, 15:25

good posts both...thank you.

Just another quickie question. Is this an autothrottle?

Have experience with thrust limited aircraft, specifically the A320 at high operating weights. Bit spoiled now as the 737-700 quite capable in the thrust to weight category. Good insight though from Iomapaseo: just because you can comfortably get up there, doesn't mean it won't get real interesting in the event of a serious malfunction(s).

One of the casualties of the switchover from the old generation to the latest and greatest from Seattle and Toulouse is an assumption inherent in computers that "it knows best". When once upon a time the question of when to climb was answered by references to things like weight, temperature, and buffet margins, an inexperienced (and some experienced) FMS whizkid might answer, "when it says we'll save gas by doing so, ie step climb."

But don't get me started on that thread...

Willie Everlearn

17th Nov 2004, 15:26

West Coast

If you look at the QRH, or Supplementary Procedures, you are advised that increasing your speed from 240 to 300 can take 5,000 to accomplish. That’s not news. It’s been there for a long time.
Bearing this in mind, I’d have to agree with you, if your sim instructor didn’t properly or adequately brief you (or these guys) on the double engine failure, you would probably wait to reach 21 to accelerate.
Not a good idea. Right?

One thing that bothers me as a TRI on the RJ is that most students are quick to say the Bombardier QRH is garbage. I can assure you, the Boeing, Airbus (and many others) aren’t much better. These documents have to meet an international language requirement and that can present difficulties when writing a QRH or any technical document. All manufacturers toe the same line. All manufacturers have their QRH issues.

That said, I make it a point to tell my students,
“IT’S ALL YOU’VE GOT ON A DARK AND DIRTY NIGHT!!!!
You better get comfortable with it.
You better do your thinking and understanding of it at home where it’s warm and dry.
If you’re not comfortable with it, ASK!!! While you still have the chance.”

That’s not news either, but it is reality.

:(

JD

If you\'re flying a 700, your Smiths is more capable than the 4200. In all probability, your PERF data more reliable as well.
It definitely has a high altitude wing, which is a comfort.

BTW,
I\'d also be inclinded to consider the oxygen mask as well in this situation, in anticipation of \'bad things\'.

For me, predictions are predictions. From the early days of computers, garbage in=garbage out.

Some things never change.

:ok:

punkalouver

19th Nov 2004, 00:47

Data Indicates Relight Attempts before RJ Crash
NTSB analysis of the flight data recorder (FDR) and cockpit voice recorder indicates that the flight crew of a Bombardier CRJ200 tried to relight the engines several times before the airplane crashed near Jefferson, Mo. Both pilots were killed in the October 14 accident. The FDR shows that while the regional jetliner was at 41,000 feet on a repositioning flight the stick shaker and stick pusher activated several times before the airplane entered an aerodynamic stall. Almost simultaneously, both engines shut down and the air-driven generator automatically deployed. According to the emergency checklist for a dual engine failure, there are two ways to relight the engines. One option is to use a windmill restart, which requires at least 300 kias and the core of the engine to be either 12 percent rpm above 15,000 feet or 9 percent rpm below 15,000 feet. The FDR data shows that the airspeed did not get above 300 knots and that there was no measured rotation of the engine core. The second option is to use APU bleed air, which has to be accomplished at 13,000 feet or below. The FDR analysis indicates the APU was on and that the airspeed was sufficient for an APU start.

blackmail

21st Nov 2004, 19:23

hello everyone,

very sad accident here, but i think the relight procedures should be designed as simple as possible with a relight enveloppe as large as possible. i don' fly this airplane but 13000ft before the apu can be used for a starter assist relight seems a bit marginal?
300kias for a windmill relight looks also to be on the high side.
maybe the beancounters at bombardier didn't want to invest in a stronger apu & more robust engines during certification?

i can imagine that stalling at that altitude combined with a dual flame out at night might be a handfull for any crew.

what is sometimes overlooked is the psychological & emotional stress you go through in such a situation. suppose that when an awfull thing like this happens, as your first reaction, you correctly or incorrectly thinks it's because you goofed up somewhere, well it is then very difficult to set this mindset aside & move into high gear to cope with the emergency. training, training, crm & company safety culture can point into the right direction, but all this costs money.

411A

21st Nov 2004, 19:37

All well and good, blackmail, but you must remember just what the aeroplane was designed for....IE: regional air services.

For junior jet guys to think they are in the big leagues with their junior jet is sadly mistaken.

Now, IF these crew had been/are trained accordingly, then these problems would not crop up...unless of course ego takes over (gosh...what a noval idea, for junior jet guys)...then the problems are a plenty.
Now, before acidic comments from these folks are posted....hey, the CRJ is a commuter airliner...and not a wide-body jet designed for high altitude, long range ops.
Fly it within the designed parameters...and problems go away.

Simple as that

Rocket science it ain't.:uhoh:

West Coast

21st Nov 2004, 20:59

"CRJ is a commuter airliner...and not a wide-body jet designed for high altitude, long range ops"

Long range ops, no alright. They however operate thousands of times a day in the high altitude structure without incident. One accident and all the years of safe operation are shot in your myopic viewpoint. These "junior jet guys" have also killed a lot fewer passengers than your era did.

411A

22nd Nov 2004, 02:13

Killed a few less, West Coast?

Yes, true, but then again the junior jet guys have not had long enough to try....give 'em time.
Smaller machine as well.

It is just as well that the aeroplane is so forgiving....down low.
:hmm:

West Coast

22nd Nov 2004, 02:25

What do you consider down low?

411A

22nd Nov 2004, 04:46

Specifically, takeoff and landing, West Coast.

For example, there is a very good reason that some first generation jet transports...the Boeing 707-100 and early -300 aircraft for example, with their slow to spool up engines, and poor handling foilbles, crashed a lot, early on.

Guys right out of DC-6's/Constellations simply were not trained well enough, and the record clearly shows this.
You don't have to take my word for this, look up some of the older retired pilots who flew these old aircraft or, review the accident/incident statistics.
And, this does not even touch the jet upset problems they had...in several cases engines chucked right off the pylon on the way down.
When I went to jet aircraft, I was trained on the 707-320B advanced, and then stepped into old straight-pipe -300's. The folks at PanAmerican had the answers , and I sure was glad I listened.

As one old Captain there mentioned...'ah, the good 'ole days, NOT'

ironbutt57

23rd Nov 2004, 03:17

Yeah sure is a lot of fascinating reading on jet-upset incidents on the older aircraft....test pilots with passengers...maybe the aircraft were rushed into service too quickly with lots of flight regimes still unexplored..and aircraft that were a lot less docile than the ones we operate today...

punkalouver

24th Nov 2004, 00:47

Ever hear about the Lufthansa guys on a training flight in a 720 that crashed while trying a roll? I have heard that they had already done one successfully.

flaps40

26th Nov 2004, 08:23

This thread seems to be going a bit off-topic suddenly!

To answer some earlier questions, the CrJ 200 does not have autothrottle.

Unless at very light weight on a cold day it will not usually manage to climb above FL370. The FMS will tell you (if you ask it) whether a nominated FL is acheivable or not, but this facility is not automatic

Most crews use VS autopilot mode for climb above Fl250 approx just to keep the profile smooth.

Crews do seem to be fascinated by the idea of making it to FL410 when possible - thats human factors for you.

There have been a number of incidents where the stick shaker sounded unexpectedly during high altitude climbs, and it is very common for the aircraft to reach the desried FL but then not to be able to accelerate if crews elect to climb above optimum (nb sometimes for wx avoidance or other good reasons). A good guideline seems to be a body angle of 2.5 degrees or less, below which the jet will accelerate ok past the bottom of the drag curve.

The double engine failure is fairly straightforward but there are several pages of drills and also a number of potential errors and most crews do not do a very tidy job the first time they see it in the sim! Second and subsequent attempts are usually much more successful. The posts relating to training are therefore probably very pertinent, so long as we are talking about initial or recurrent typerating training.

The stall alarms are noisy and brightly lit and a combined stall with double flame out (and the VERY noisy ADG electrical power source) will certainly make you jump!

The aircraft will of course depressurise (the rate will depend on the integrity of the doorseals etc, but probably fairly slow rate and therefore potentially insidious, the CABIN ALT warning may go unnoticed among the very many other related EICAS messages).

After the decision to discontinue windmill starts is taken (ususally by about FL 150) there is quite a lot of time available, most experienced crews maintain fairly high speed to FL130 and then fly a level glide at FL130 while using the APU start technique and decelerating to 180 kts approx. Further glide at 180 kts approx gives about 1200 ft per minute descent and about 6 degree glide angle. If in the sim try to use a glideslope but aim to be right on the full scale flydown pointer and it will be about right, clean

note, no APU means no flaps available, most instruments dark, no DME, no autopilot etc. In this case I understand the APU was lit which makes it all a lot easier.

My main point - this is a tough drill even from high altitude with lots of time. If you have briefed it and done it once or twice in the sim then your chances are much better - that is what sims are for

Elliot Moose

26th Nov 2004, 18:47

Unfortunately, most FAA 121 operators have absolutely no interest in training engine failure at altitude (either single or double) even less in taking time for glide or high altitude stall work. The entire attitude exhibited by every one that I have dealt with has been "get them through the checkride" and don't worry about the rest. One carrier basically forbade "screwing around with the FMS" as that is "an IOE thing" even though the FMS is a key instrument in the CRJ, and one that can be a life saver in a tight spot. :mad:

The absolute best that I've worked with have at least briefed some of these things, but still would not actually include them in their TCM as training items. The FAA sure hasn't been pushing either. The JCAB (Japan) insists that these things be accomplished satisfactorily on initial courses, and mistakes are frequently made by even the best prepared students (we are talking ex-747 captains here that are the best pilots I have dealt with PERIOD:ok: ). Those folks have the right attitude about training--it costs a lot more, but I think it pays off in the long run.

121 operators are generally happiest if their students can get through with a giant classroom groundschool, little or no FTD time and a max of 8 sims before a canned checkride. In that kind of time you just get the basics unless you're a really fast student. I have talked to experienced RJ pilots who had no idea that there is a way to use the FMS to fly a full procedure approach in the RJ. Others have never seen an ADG drop (double gen fail) or trim runaway, and many would tell you that there are immediate action items for a simple engine failure (flameout--no damage) when this is only considered an ABNORMAL item.

CRJ2

17th Dec 2004, 17:41

Hy @all!

Any news about the reason for this accident???

gear down props forward

2nd Mar 2005, 08:30

the following link sends you to a television station's transcript of the ATC audio tape concerning the crashed pinnacle RJ. it does not credit any sources or have much detail. no subscription required to read it. gives an idea of what the actual audio tapes may contain.

http://www.kstp.com/article/stories/S6577.html?cat=1

dudduddud

2nd Mar 2005, 13:16

Godspeed, chaps.

Frangible

3rd Mar 2005, 15:08

"Having some fun"???
Talk about famous last words.

hobie

3rd Mar 2005, 17:43

It seems 41,000 was at max for the RJ's published limits .......

"Maximum Service Altitude: FL410"

320DRIVER

3rd Mar 2005, 22:17

The Bombardier website says that the max operating altitude for the CRJ200 is FL410... so if those guys were at the correct weight and speed, I dont see how why that aircraft should stall and loose two engines... maybe the comment "having some fun" was misinterpreted and it could well have been a cocky reply to the controller enquiry at seeing the aircraft at FL410...

...if on the other hand they purposely went into slow flight then they were asking for trouble.

Just another eye-opener for us all not be tempted to do "test flights" in an uncotrolled manner especially during such positioning flights.

Are U.S. airlines obliged to have a Flight Data Monitoring programme in place?

Elliot Moose

5th Mar 2005, 23:15

if those guys were at the correct weight and speed, I dont see how why that aircraft should stall

Buy 320 driver a beverage of his or her choice!:ok:

...if on the other hand they purposely went into slow flight then they were asking for trouble

Then again, maybe they didn't know they were in slow flight. I don't know about these boys, but a HUGE number of jet pilots out there wouldn't know--and a pile of airlines have little or no interest in stopping to teach them (or at least they didn't before this happened)

Ignition Override

6th Mar 2005, 01:28

This is just a reminder that one of the doomed pilots had a wife and a young child, according to one of their Line Check Airmen who spoke to me in an airport.

I've skipped most pages of this topic, but are most of the CRJ pilots aware of the minimum indicated airspeed for the highest altitudes, or are they required to check a plastic card which shows a given weight/altitude/ min. indicated speed for 1.3 and 1.5 gs? On the larger plane which we fly, we learn quickly that about 250 KIAS can be a limit, but a heavy 'stretched' version can require at least 260 plus, never mind an immediate clearance to hold on the arrival, NOW. Even a very experienced (two-pilot, no automation :ooh: ) crew got into some trouble, briefly, when ATC abruptly assigned them to hold in three more miles, on a very busy arrival into ATL. At about the very same moment, a cabin crewmember mistakenly rang the c0ckp1t chime THREE times (suggesting trouble...), because the captain had asked her to always give them two chimes. All of this as they leveled off and pushed the two throttles up, all by manual control :eek: . They must have thought/assumed that there was an emergency in the cabin.

In retrospect, even with 7,000+ hours for each of them, they were both distracted by the three chimes, and the flying pilot would normally have quickly checked a card for the required holding speed for a heavy weight plane (106,000 lbs +).:confused:

Elliot Moose

6th Mar 2005, 16:16

I-O
The min speed as normally used in the US would be "green-line" which is about 1.27XVs. Less than that and you're behind the power curve. Climb capability is usually limited by when the aircraft stops climbing (500fpm nominal is the norm). Min climb speed is .70 for most operators, and will ensure the aircraft will stop climbing well before the buffet margins are a serious factor.

The only way to climb into a sticky situation is generally to go slower to trade airspeed for altitude, but once you try to level, it won't accelerate, and may continue to lose speed if you are "zoom climbing" to get the altitude. Some operators have the buffet cards, but they aren't actually used that much due to the above reasons.

lasernigel

13th Jun 2005, 20:39

More news on the cockpit voice recording (http://www.msnbc.msn.com/id/8205660/) now being released.

RRAAMJET

13th Jun 2005, 23:33

What a tragic result. I find it hard to believe that these pilots did not know, or were unaware of, engine restart approx. parameters. Did the APU start? Will it even start until below the 30's? Best glide speed vs. eng. relight?
What a mess; I strongly suspect inexperience was a player from the FO's comments on the thrill of reaching the 40's. (If he had been using meters, would they have even known the difference between the 30's and 40's? I suspect not. 40K feet - big deal...)

And as for the ridiculous remarks of the Air Travellers Association rep. - well, they're all pilot haters anyway who think we're overpaid and should take big cuts to help lower their ticket prices. AKA the " Rude wannabe-CEO's Alpha-male flight-attendant-ignorers Association". I've had a meeting with one of them before, during a wx delay at MIA, during which the guy went beserk and started ranting about his "rights" and Sen. John McCain. Whatever. :yuk:

barit1

14th Jun 2005, 14:24

13 June (http://www.usatoday.com/news/nation/2005-06-13-ntsb-crash_x.htm)

and

14 June (http://www.usatoday.com/news/washington/2005-06-13-pilot-violations_x.htm)

RatherBeFlying

14th Jun 2005, 23:26

If the a/c is certified to 41,000, I can expect it was a big surprise to the crew when they got both a stall and a double engine flameout.

It seems that there are weights and temperatures that allow that altitude and others that don't.

Did the crew's training cover variation of maximum altitude with weight and temperature?

Did the crew's training address what could happen in a high altitude upset and what would lead to one?

Or was the crew just told to conform to whatever dispatch fed them without understanding the constraints?

What would happen to a crew that felt a higher altitude than that given by dispatch would obtain better conditions?

What knowledge would they need to make a good decision?

ZQA297/30

15th Jun 2005, 00:19

Even if the aircraft was at correct weight and speed for 410, if it had just a smidgen of leading edge contamination, the picture could change significantly.
Todays super-critical wings are very intolerant of even small airflow disruptions in the first 1/3 of the chord.
Climbing through just a wisp of cloud with 10 or 15 seconds of un-noticed light icing could change the characteristics of the wing enough to surprise the unprepared when in the narrow end of the envelope.

danke

15th Jun 2005, 01:24

http://www.ntsb.gov/events/2005/Pinnacle/exhibits/317489.pdf

411A

15th Jun 2005, 08:57

Another example of junior jet pilots (IE: regional jet flight crews) provided insufficient high altitude performance training by the respective airline...with bad results.

Higher is not always better, as these guys certainly found out, in short order.:uhoh:

barit1

15th Jun 2005, 12:16

Am I alone in my skepticism over the title of this thread?

I looked up "incident" in my dictionary, and have to question whether this is an "incidental" topic.

lomapaseo

15th Jun 2005, 12:29

barit1

your coment about incident? is a few days late.

The original poster seems to have posted breaking news where there was no benefit of numerous pages of intelligent discussion here on PPRune.

About the only way to satisfy your concern would be for an update of the thread titles to suit the latest information.

I don't see that happening on a public message board.

West Coast

15th Jun 2005, 13:58

"Another example of junior jet pilots (IE: regional jet flight crews) provided insufficient high altitude performance training by the respective airline...with bad results"

You say another, list other RJ incidents in which these junior jet pilots screwed up at altitude. All things considered, they are doing better than your generation ever did.

Again, list some of the incidents.

RatherBeFlying

15th Jun 2005, 21:50

Yes, danke, the NTSB report has the answers -- thanks.

Ryan_not_fair

16th Jun 2005, 12:44

One of the saddest threads I have every read on Pprune and not just because of the unfortunate outcome but also, I’m afraid, because of the nature of some of the posts. I have been following this from the very start and I should congratulate some of the early posters for their insightful observations while the facts were still very thin on the ground.

We now have an NTSB report which gives us a much fuller picture of the tragic events that took place, but I am shocked by the callous and blinkered interuptation that some are putting on this report. It is clear to me that there are at least 4 significant contributers to this fatality but some are happy to pin the entire events on a reckless crew who were just having a bit of fun. Oh, how quick the authorities were to release that gem of a one liner. It was released in the hope that everyone would agree with their interuptation and go away quietly, and I am saddened at how quickly the aviation fraternity has obliged. We owe it to the unfortunate crew not to let this happen. I urge all to reread the report and re evaluate your opinions on the events that happened. Here is how I see it.

The Crew.

There can be no question that the crew took the a/c to it maximum certified limit of FL410 having been cleared to a much lower level, but as someone has already pointed out, it was the maximum certified limit and not beyond it. I am only too well aware of the “special” aerodynamic circumstances that exist at this altitude and that special training is required to both handle an a/c at that limit, and to recognise the onset of the various phenomena that occur there. This wasn’t provided nor was a lower limit imposed by the operator through a mandatory SOP or similar instrument at their disposal. I find it interesting that the report notes that the service agent who met the crew prior to them embarking, found them in very good mood and not at all tired looking. I suspect that the crew knew only too well that they were being handed the keys to the sweet shop and that the special circumstances surrounding the flight, a repositioning flight with no pax or cargo, would give them the opportunity to go for the magical 41. I would even speculate that they may have even discussed it before hand and would credit them with having probably evaluated the risks within the limits of their knowledge, however flawed this may have been. Unfortunately they were not prepared by the Operator for what was to come.

The Operator.

I hold this bunch in the highest contempt of all. Interviews with sim instructors and checkairmen revealed that high altitude climbs and recommended climb profiles were neither conducted, discussed or demonstrated during sim training sessions with crew on this type. They were simply discussed in the jet upset module of the ground studies. This to me is only acceptable if accompanied with an SOP or some other mandatory circular to all crew forbidding them from attempting to get to an altitude above say FL370. Further more, the report reveals that the only sim based upset training provided to new pilots consisted of 20 minutes where the operator didn’t even allow the pilots under instruction to climb to FL350 but positioned them there electronically to save money (or time as they quite disingenuously put it). This to me demonstrated this operator’s commitment to safety right there. Appalling. The report has a comment from a management pilot from another carrier who operate the same fleet, and he stated that his FDR data analysis from repositioning flights “seems to bring out the worst in his pilots” with unusual attitudes and other manoeuvres regularly being tried. I assume Pinnacle have similar data but didn’t use it to prevent this practice – it probably costs too much. Just look at the number of changes both Pinnacle and Bombardier have made to ops procedures since this incident – staggering in my opinion.

Bombardier

Why oh why would you apply for and get a certificate to operate an a/c at a flight level that required at the very least special training. Several pilots are on record that while they were able to climb to FL410 they were not able to maintain it due to deteriorating performance. If FL410 can’t be safely maintained, why is it certified??? One experienced instructor commented that FL410 required “extreme” attention while another stated that “FL410 is not a FL you want to be at very often” Because it was certified, the two crew in this accident probably felt that it could be safely achieved.

FAA

Why would they give a certificate to an a/c to operate at FL410 with these characteristics? Further more, they issued 59 violations against Pinnacle between ’98 and ’04, and some were not even remedied by them. However, the speed at which Pinnacle implemented every recommendation of this report suggests that something is very wrong.

Conclusion.
Come on folks; don’t let them take the easy way out.
.

May they rest in peace.

nugpot

16th Jun 2005, 16:28

This topic has also become a hot topic on the airliners.net forums.

I would like to answer Ryan_not_fair on some of his comments.

The CRJ 200 (which I still fly), requires no special training to be flown at its certified ceiling. If you follow the Bombardier normal climb schedule and max weight/altitude planner (both available in the cockpit), you will arrive at FL410 at M.70 and if you have correctly interpreted your weight for altitude planner, you will accelerate to cruise speed. I have been to FL410 - it is a non-event.

I do not want to bash the unfortunate crew of the Pinnacle flight, but they arrived at FL410 at M.64, on the wrong side of the drag curve. In no documentation or training that they have received will that MachNo be mentioned. The aircraft continued to decelerate until first the stick shaker and then the stick pusher operated. Fighting the stickpusher brought them to 75 KIAS and a full aerodynamic stall. This flamed out both engines. (No2 overtemping to 1250 degrees C).

Just as there is no reason to train pilots on other aircraft to fly at their respective certified ceilings, so there is no reason for the CRJ.

Bombardier and the operator made changes to their procedures as a typical kneejerk reaction.

Just as a 747 won't maintain FL410 at high weights, the CRJ can only do it when light. Does Boeing also have to recertify the 747?

Because RJ's mostly fly short sectors, we almost never have the right combination of weight and distance to get to FL410. Instructors at Pinnacle would almost certainly never have been there in the real a/c. All the CRJ sims that I have been in are much more unstable than the real thing and I think that the comments in the NTSB documentation are over the top.

I am not defending Bombardier, Pinnacle or the CRJ. I take issue with the fact that training is now suddenly necessary to fly an a/c at its certified ceiling or forcing Bombardier to limit the a/c to lower levels because one crew could not recognise and correct a low energy situation and then compounded the error by fighting the stickpusher.

I have looked at all the data available at the NTSB site. The aircraft operated as advertised.

barit1

16th Jun 2005, 16:35

I certainly agree the training was lightweight (metaphorically speaking) but we have several unknowns:

What was SAT at 410? If the atmosphere was considerably off ISA, the speed margin in the coffin corner might have vanished. Could a highly experienced crew have handled the situation on that day? Probably depends on instability in the atmosphere. These guys plainly ran out of margin.

The mere fact that the aircraft was cert. to FL410 DOES NOT mean that it is safe in any and all atmospheric conditions way up there.

Relight training was also probably lacking.

nugpot

16th Jun 2005, 16:55

Could not find SAT in FDR data, but TAT was -35C - so SAT should be in the region of -50C (ISA +5), well within normal range for RJ at FL410.

411A

16th Jun 2005, 19:52

Sadly, West Coast, you did not properly read my statement.
Read it again and you will clearly see that I referred to insuficient crew training provided by the respective operator.

Did the crew mis-handle the aircraft?
Clearly they did, however I fault the airline, not necessarily the pilots...they clearly did not know any better.
Should have, but did not.

I wonder if it is par for the course with regional jet operators?:uhoh:

DA50driver

16th Jun 2005, 22:48

I fly corporate jets certified to 49000 and 51000 respectively. The number one issue regarding high altitude flight is speed. Do not let it get loe, climb at 100 feet per minute if you have to. Or go back down again. I used to fly with a guy who would follow the profile all the way to altitude, and we would not accelerate at all after level off. Going that slow makes it feel like you are balancing on a beech ball. A little turbulence can be enough to make you soil your shorts.

These are things that you should know by the time you are the PIC on a jet.

Ryan_not_fair

17th Jun 2005, 00:26

NUGPOT

I cannot argue with your insightful response and I applaud you for your consistent stance on this tragedy. I also thank you for you link to the airliner.com forum which is most informative. I think I understand the stance you are consistently assuming in that the a/c does exactly what it say’s on the tin and these guy’s were unfortunately on the wrong side of the curve. Far too simplistic for me though.

My point is that they shouldn’t have been there in the first place as the operator had an obligation to train them in the handling of the a/c within the operating envelope of the a/c. The NTSB clearly state that this wasn’t provided.

I am also interested in your comments especially as you have been regularly operating this type at FL410, but my concern is that numerous other pilots have testified to the NTSB that this wasn’t possible for any prolonged period, regardless of configuration, and the longer they spent at this FL, the more unstable the performance of this a/c became. I think it highly relevant that the NTSB allowed a comment from a very experienced sim instructor, which said that “extreme attention” is required to fly this a/c at this FL – for God’s sake, the last thing that any pilot needs at any flight level is EXTREME ATTENTION to anything – don’t care whether you are 30 ft off the ground or at FL410.

Question – If certified to a specific FL, surely an SAT or TAT correction is specified in the perf data!!

Instant Hooligan

17th Jun 2005, 19:51

Temp at FL410 was ISA +9.4 according to the NTSB report and is easily available in that fashion(to whole number) in flight.

Ignition Override

18th Jun 2005, 09:58

As 411A addressed, higher is better? This is the oldest theory regarding the most economical altitude for any jet.

Why let theory lead you into a very high workload situation where it is your decision to limit, distribute the workload in a manner which seems reasonable and prudent as PIC, never mind any compromise because of fatigue and/or weather, thereby allowing some possibility of CRM back-up?

On one of our flight plans for a very short leg, it stated that the fuel burn at about 12,000' was the same fuel burn as a climb to FL200, followed by an immediate descent. The flight planning software apparently was created by Jeppesen for airline Dispatchers. Why work your butt off to go up then back down like a 105 mm. howitzer shell if it is three times the work, especially for the non-flying pilot in a plane with no automation except for altitude hold [:uhoh:]? Navigating, figuring crossing restrctions, setting hydraulic pumps, manual cabin, ATIS etc; none of this is done automatically (remembering to somewhere check the remaining fuel) . This does not include distractions from the cabin or weather, nor a nagging cabin altitude that won't descend at idle with airfoil anti-ice on.

barit1

19th Jun 2005, 15:41

9 June (http://www.ntsb.gov/ntsb/brief.asp?ev_id=20050616X00788&key=1)

and
10 June (http://www.ntsb.gov/ntsb/brief.asp?ev_id=20050616X00790&key=1)

320DRIVER

19th Jun 2005, 19:58

Quite worrying... is it a case of bad envelope definition by the manufacturer or is the operators pushing the limit?

Mad (Flt) Scientist

19th Jun 2005, 20:04

"The airplane was at Mach 0.070 when the flight encountered a downdraft and the stick shaker activated."

Not surprising really, I'm impressed the plane was flying at all at that speed.....

barit1

19th Jun 2005, 21:40

I'm impressed the plane was flying at all at that speed.....
It wasn't.

ZQA297/30

19th Jun 2005, 21:49

"Mach .070"????
Now that's slow, didn't know you could read that low.

Mad (Flt) Scientist

20th Jun 2005, 01:00

In case it's lost on anyone:

1. it's sarcasm

2. if the NTSB can make such a simple error in an abstract, perhaps one should consider VERY carefully the veracity of ANY information, whatever its source, and not leap to conclusions ....

AirRabbit

20th Jun 2005, 03:28

I'm not sure that an NTSB typo really should call into question the rest of the story -- however, I DO think that ALL the facts need to be determined BEFORE someone starts trying to build a case in any particular direction; and I would wager there are at least some who are trying to do just that. The problem is, for us who are interested but not connected, trying to determine if a specific "fact" is truly a fact or something placed in that light to lead us interested but not connected persons to come to a conclusion desired by an interested AND connected party.

It's like the song in the musical "Mary Poppins," ("...a spoonful of sugar helps the medicine go down...") Para-phrasing, a spoonful of truth helps the not-so-true get swallowed. Watch carefully. Read carefully. Accept little if anything on face value. Been there; Done that; Had the experience of having otherwise well meaning people try to force sugar-coated "non-facts" down my throat despite my loud protestations. :yuk:

AirRabbit

Willie Everlearn

20th Jun 2005, 10:57

Mach Transducers

The CRJ mach transducers display the equivalent mach on the PFDs. Climbing, it is first displayed at an equivalent mach value of .45 and above. Descending, mach is removed at .40.

This is clearly, I suggest, the misplacement of a 'decimal'.

:oh:

xsbank

20th Jun 2005, 12:10

No comment on the initial decision to fly this a/c at an unfamiliar altitude/regime.

As a past instructor on the 604, very similar to the RJ's systems, I have observed many difficulties in the operation of the (very simple) bleed air system - the correct selection of the (4) switch-lights would be essential for the success of an APU start of the first engine, and if attempting a relight at below 13000 with the incorrect bleed settings, a mundane selection of one switchlight would have precluded any attempt at a relight and the ground would seem very close at that point.

This situation would see the crew attempting to function in a very noisy and very non-standard environment:
The ADG would have been deployed - noisy, vibrates tremendously, and very distracting
I think the autopilot disconnects on an RJ with power loss? It does not on a 604. Somebody needs to hand-fly?
Reading the QRH with a flashlight?
There would have been a stack of messages on the EICAS with the associated chimes and flashing Cautions/Warnings
Getting the APU started?
ATC?
O2 masks? If so, difficult communications between crew with loud Darth Vader noises (that's a second area where finger-trouble is common)
Navigating? Where the hell is that airport? Is someone attempting to program the FMS and operate the QRH?
Will the APU start?
F/O overload? Probably.
Stress level off the scale - a long time to contemplate the end.
The wreckage was inverted - another stall? Probably they were very unfamiliar with hand-flying, and following the correct (seemingly too-fast) airspeed means giving up a lot of altitude.

Once these guys lost the two engines, and recovering from the initial stall, doing the rest correctly and in a timely fashion would be stressful enough in the sim, let alone in the real a/c, and you must be trained to make the right decisions when it all happens. E.G: do you driftdown initially to evaluate? If you decide to do this, planning eventually to start the APU, you initially decrease your airspeed to about 210 knots for very leisurely descent. This low speed would probably cause the N2 cores to "lock;" returning to windmill speed would require giving up a LOT of altitude, and the engines are 6.2:1 ratio so you would get a very lackadaisical response from the N2...you would have to hold that dive for a long time.
As your altitude decreased you would also have to decrease your driftdown (=VFTO?) and this would also always be the slowest speed you fly at...another page in the QRH.
Or do you immediately point the nose at the ground, right after stall recovery, effectively diving the a/c to get the cores to spin, and decreasing the time you have to "manage" this "event?"
A bad one, gentlemen, rife with speculation for sure, but I have seen this screwed up in the sim in a 604, so I can see the pitfalls.

barit1

20th Jun 2005, 13:33

I'm not sure that an NTSB typo really should call into question the rest of the story --

These NTSB preliminary reports are probably typed by someone who's more often doing train, bus, tanker, or pipeline reports - and they're probably not proofread.

e.g. "On February 20, 2005, a British Airways Boeing 757-400, registration G-BNLG, experienced an engine failure shortly after takeoff from Los Angeles International Airport, called PAN, and request to divert to Manchester, United Kingdom. The point of intended landing was Heathrow International Airport, London, United Kingdom. There were no injuries to the 370 persons on board and the airplane landed safely."

The "oopses" here don't invalidate the whole story, do they?

westhawk

20th Jun 2005, 22:42

I read the CVR transcript from the Pinnacle airlines CRJ accident investigation released by the NTSB last week. Wow. The comments made by the crew near the top of climb and during level-off indicate that they were aware of the decreasing speed/increasing AOA condition they were in but did not take action to reverse this trend or discuss the implications. To those experienced in high altitude flight, the implications are obvious. Stop that trend now by reducing pitch attitude before we get too slow to recover our speed. For reasons as yet unknown to me, this crew appears not to have appreciated the critical nature of this trend. As pointed out by DA50driver, the rate of climb must be limited by the conservation of climb airspeed/mach number. Generally, a climb speed somewhat greater than that called for by the optimum climb profile is selected to provide a positive margin against the possibility of encountering less favorable atmospheric conditions during the remainder of the climb. Once the speed is allowed to decay below optimal climb speed, climb rate must be reduced to arrest the trend and reduced further to recover lost speed. If action to arrest the decay trend is delayed too long, a descent will be required to prevent a stall. Many corporate/charter jet pilots learned these truths in the air while serving as SIC under the tutelage of an experienced PIC. I would expect that many airline pilots have learned by a similar process. I wouldn't be suprised to see this scenario become a new focus in initial training. Hopefully, a reading and analysis of the facts gathered in this investigation will be of instructional value to many. Regardless of where the blame/responsibility is ultimately placed, the facts brought to light by this investigation provide us all with an opportunity to learn some valuable lessons from the mishaps experienced by others.

BusyB

20th Jun 2005, 23:31

barit1,

'These NTSB preliminary reports are probably typed by someone who's more often doing train, bus, tanker, or pipeline reports - and they're probably not proofread."

I find it difficult to believe some of the cr*p on these forums, please tell me more about the 757 LAX-LHR.

barit1

20th Jun 2005, 23:55

Sorry you missed it! (http://www.ntsb.gov/ntsb/brief.asp?ev_id=20050307X00273&key=1)

acm

21st Jun 2005, 09:54

" have a little fun up there"

I don't know what's funny to be a FL410, except for extra shot of cosmic radiation.

Not a very mature crew, with an awful training record...

chuks

21st Jun 2005, 12:01

Often I find the quality of the responses to this or that posting much more interesting for what they say about the mindset of the person posting than for their actual content. There must be a lot of bitter and twisted souls out there just waiting for the chance to dump on someone for either a real or presumed mistake.

As to this 'incident': It sure does look as though the crew in question had not thought through the amount of energy required versus the amount of energy available for sustained flight at FL410.

The first high-altitude airplane I had any significant experience was a Cessna 441 fitted with the less-powerful, original engines (most have now been modified with flat-rated engines that allow them to climb much better).

I used to like to get it up to FL310 on the way from Kano to Lagos, when it would take me all the way to Bida just to reach that height. Well, a look in the book told the tale: conditions were ISA +15° C so that I was asking this machine to fly above its design density cruise altitude. Of course there I was operating a straight-wing airplane in day VMC with all the time in the world to watch what was happening; there were no distractions due to complying with ATC instructions or following an airway more than loosely, say. Too, I was hand-flying so that I could feel what the machine was doing. So I was fully set up for a learning experience, rather than just asking the machine to take me to a particular level simply because the label on the can read 'FL310'.

The Dornier 328 just stops at FL350. That's all the software will give you, although I suppose you could disengage the autopilot and play 'Test Pilot' if you really needed to risk that. When you check the book you will find that at that level Max Cruise and Long Range Cruise are the same, so why bother going higher? The airplane will reach that level with no trouble where I suppose it must run out of steam trying to go much higher, just as this accident aircraft seems to have done. So you might say the 328's designers chose to keep 'junior jet pilots' like me out of trouble.

In this incident it sure does look as though the crew were surprised by something they probably already knew about, but hadn't bothered to think about. Given that they paid such a high price we could probably relax a bit and wait for the official report before going much further than that.

LOKE

22nd Jun 2005, 03:12

Just Before Dying, a Thrill at 41,000 Feet

By MATTHEW L. WALD
Published: June 14, 2005
WASHINGTON, June 13 - Alone in their 50-seat commercial jet, the two young pilots decided to see what it could do.

According to documents released Monday by the National Transportation Safety Board, they climbed so fast that they were pushed down into their seats with 2.3 times the normal force of gravity, zooming toward 41,000 feet, the limit of their Bombardier CRJ200.

"Ooh, look at that," said the second-in-command, Peter R. Cesarz, 23, apparently referring to cockpit readings. "Pretty cool."

"Man, we can do it," said the captain, Jesse Rhodes, 31. "Forty-one it," he said, referring to the maximum altitude.

A few minutes later, though, both engines were dead, and the pilots were struggling to glide to an emergency landing at an airport in Jefferson City, Mo. "We're going to hit houses, dude," one of them said.

The plane crashed two and a half miles from the runway, missing the houses but killing the pilots.

On Monday, the safety board opened three days of hearings into the crash, which occurred last Oct. 14 on a night flight from Little Rock, Ark., to Minneapolis, to reposition the plane for the next day's schedule.

Among the questions at issue is whether the plane's two engines, which are designed to be capable of restarting in flight, may have seized up, resisting four efforts to get them running. Another is whether the airline, Pinnacle, which is rapidly growing and moving young pilots from turboprops into jets, provided appropriate training.

Some investigators say the pilots flew the plane far harder than an airline would fly with passengers on board, and in testimony on Monday, Terry Mefford, Pinnacle's chief pilot, agreed.

"If there's people in the airplane," he said, "you can count that the crew members are pretty much going by the book."

Mr. Mefford also said that since the accident, he had heard talk of a "410 club," whose members had flown the Bombardier to Flight Level 410, or 41,000 feet. Investigators for the safety board apparently heard similar talk. "Investigators formed the impression," a board report said, "that there was a sense of allure to some pilots to cruise at FL 410 just to say they had 'been there and done that.' "

The two pilots had set the autopilot to take the plane to its 41,000-foot limit, but instead of specifying the speed at which it should fly while climbing, they specified the rate of climb. When the jet reached the assigned altitude, it was flying relatively slowly.

The transcript of their conversation as captured by the cockpit voice recorder suggests exhilaration. An air traffic controller with jurisdiction over the flight asked at one point, "3701, are you an RJ-200?"

"That's affirmative," one of the pilots replied.

"I've never seen you guys up at 41 there," she said.

Then there was laughter in the cockpit.

"Yeah, we're actually a, there's ah, we don't have any passengers on board, so we decided to have a little fun and come on up here," one of the pilots answered.

In the thin air, though, the engines had less thrust, and the plane slowed further. The nose pitched up as the autopilot tried to keep it at the assigned altitude, and then an automatic system began warning that the plane was approaching a "stall," in which there is too little lift to maintain flight.

"Dude, it's losing it," one pilot said, using an expletive. "Yeah," the other said.

But as an automatic system tried to push the nose down, to gain speed and prevent the stall, the pilots, for reasons that are unclear, overrode it.

So the plane did stall, and the turbulent air flowing off the wings entered the engines, shutting them down.

"We don't have any engines," one of the pilots said. "You got to be kidding me."

At that point, the safety board says, the plane was within gliding range of five suitable airports. Yet the pilots did not tell the controller the full extent of their problem, reporting that they had lost one engine, not both, and it was not until 14 minutes later that one said: "We need direct to any airport. We have a double engine failure."

The airline has denounced the pilots.

"It's beyond belief that a professional air crew would act in that manner," said Thomas Palmer, former manager of Pinnacle's training program for that model of jet. He said the crew had evidently disregarded "training and common airmanship."

But the Air Line Pilots Association says Pinnacle's safety program had crucial gaps, including lack of training for high altitudes. It also maintains that the engines suffered "core lock," in which engines running at high thrust are shut down suddenly and, when the parts cool at different rates, some rotating components bind up.

General Electric, which built the engines, says they did not seize up.

To be certified by the Federal Aviation Administration, engines must be capable of restarting in flight. One issue that the safety board will have to resolve is whether the engines on this plane met that rule.

westhawk

22nd Jun 2005, 06:45

<<The airline has denounced the pilots.>>

That's typical. The operator usually starts there following a tragedy. If the pilots are not enough, the search for a suitable scapegoat will continue for as long as it takes to deflect attention away from their own culpability. Don't get me wrong, these pilots appear to exhibit a suprising lack of maturity, responsibility and general airmanship by the statements attributed to them on the CVR transcript. What I find objectionable is that Pinnacle mangement would be the ones to denounce them! Pinnacle leadership was responsible for screening, selecting, training and assigning these pilots to their duties. They also determine, by example, the corporate safety and ethics culture for the entire company and all of it's employees. It is the responsibility of every employee to do what they know is right and to always act in a way that represents the stated company safety objectives while performing their assigned duties. It is the responsibility of the company to support this expectation of professional behavior by taking every reasonable step to ensure that employees assigned to positions of such vital importance as that of a flight officer are fully trained and encouraged to exersise discretion and good leadership. Easy to say and hard to do because human behavior is not an exact science. But how does any company come to assign two crewmembers to a flight when niether of them understand the basics of jet climb performance or impending stall indications? They commented on the indications but did not demonstrate any understanding of their implications until entering the stall. Suprise! No, Pinnacle cannot escape responsibility for this outcome simply by saying the crew did not follow company procedures. Even though this statement appears to be true, it is not the whole story. Had either of these two pilots posessed even a basic understanding of jet flight characteristics, the airplane would never have stalled. Are they the only ones who screwed up? The company could have done better too. Maybe it costs to much to employ knowledgable, experienced pilots. Yeah, that's the ticket! We gotta get 'em on line cheap. As for everything that happened after the stall, they were in a very uncommon scenario that may have demanded more than they had to give. You think this one will be included in future sim training?

Pointer

22nd Jun 2005, 07:10

Excuse my ignorance, does the RJ200 have no auto throttle?

Pointer

Waspy

22nd Jun 2005, 08:45

Something not mentionned yet is how the crew got to F410. My company has a SOP to use level change (IAS) mode to climb. This has as a consequence that the "natural" tendency of an A/C to "level off", e.g reaching max 500' min ROC, at its optimum climb mach will warn you that with today's OAT, GW and thrust available, it is time to ask ATC for an intermediate level off.
Even flying a piper cub, everyone knows that as from a certain altitude and below a certain IAS, an A/C cannot be accelerated anymore?? Not to blame the crew involved, the constant use of AP has generated a "'marble ass" generation of pilots. Any opinion on this? More "unusual attitude/altitude" training required?

aardvark2zz

22nd Jun 2005, 19:45

Why couldn't they restart the other (left) engine ? The is no mention of much damage to that engine in the NTSB documents.

AirRabbit

22nd Jun 2005, 23:08

For what it’s worth guys – those of you who chose to decline the opportunity to “jump” on the pilots, who advocated a “wait-and-see-what-ALL-the-facts-are” policy, and particularly those of you who pointed out that our collective responsibility now is to learn some valuable lessons from the mishaps experienced by others (yes, Mr. Westhawk – that last comment was directed at you), please accept my most sincere compliments for a refreshing professional attitude. There are way too many “beginners” who log onto these forums to see “what the pros think” about various and sundry things. And instances like this are way too important to the understanding and future development of the younger aviators for them to see a “rush-to-vilify” other aviators. Yes, perhaps we’ll find that the circumstances surrounding this accident were self-designed and maybe self-ignored, but we may be surprised as well. Also, we may find that the airline should have, could have, would have … about a lot of things ... but maybe not.

I whole-heartedly recommend that ALL of the FACTS be determined – and I’m not just talking about “factoids” that can be used to push someone on the outside of the knowledge base toward a position that was pre-determined by the disseminator of the “factoids.” I would hope that the professionals here would not only be willing to wait, but demand that others wait as well, until the FACTS, all of the FACTS, are gathered. And then, only then, would careful consideration of those FACTS be used to determine logical, rational, and correct conclusions about what really happened. And even then, I would counsel everyone to read the facts for themselves; and not take the word of someone else, before anyone draws his/her own conclusions.

_______
AirRabbit

RatherBeFlying

23rd Jun 2005, 02:53

This is not the first time that an autopilot climb in VS mode has resulted in a stall.

I'm not excusing the crew for overriding the stall protection, but I wonder why the FAA certifies autopilots that allow the airspeed to decay as much as happened here.

I would like to see a minimum airspeed of best angle/rate of climb no matter what the autopilot mode.

Bigmouth

23rd Jun 2005, 07:10

Anybody who hires their FO's out of Gulfstream Intl.'s "program" is more concerned about cutting costs & corners than safety and professionalism.

chuks

23rd Jun 2005, 07:15

I know that we were cautioned on the transition course for the Dornier 328 about using VS (Vertical Speed) mode, that it can give problems with speed decay as the (stupid) autopilot tries to maintain a certain rate despite the engines simply running out of thrust with increasing altitude.

We have an SOP in place that requires the use of FLCH (Flight Level CHange) mode for continued climb, but good airmanship should tell you not to use VS anyway.

It can be rather interesting to watch the way the autopilot flies the aircraft, often duplicating beginner's mistakes such as failing to anticipate a turn or a level-off, or 'chasing' a signal. Of course one can put this down to poor management of the machine by the pilot, but it's not a simple 'set and forget' piece of equiptment.

When I was trained I was often told that 'the autopilot can fly this airplane far better than you can, so always use it!' That doesn't actually seem to be the case, does it?

Pointer

23rd Jun 2005, 08:33

It can be rather interesting to watch the way the autopilot flies the aircraft, often duplicating beginner's mistakes such as failing to anticipate a turn or a level-off, or 'chasing' a signal. Of course one can put this down to poor management of the machine by the pilot, but it's not a simple 'set and forget' piece of equiptment.

IMHO; if you ever let that Autopilot do things like that, you should be going back to the sim for a refresher.

The aluminium tubes we steer through the air are not toy's and yes flying a turbo prop is more fun than jets, simple reason, you should not be doing things with jets which you can with turboprops(a bit off topic), however, i use the autopilot as an extention of my skill and knowledge

It seemd that the accident involved was one where indepth knowledge of systems was absent (just my personal thought), if the autopilot is not doing what you want, you probably are using it the wrongway eg wrong mode/status for that phase of the flight.

But to repeat my question: did it have autothrottle?

Pointer

411A

23rd Jun 2005, 08:50

\\....but I wonder why the FAA certifies autopilots that allow the airspeed to decay as much as happened here.\\

Autopilots are certified to properly fly the aeroplane, in various configurations.
The particular mode of autopilot operation is normally determined by the flying pilot, after attending a properly designed ground course, base (if required) and sim training, and the very necessary line training required by the respective airline, in conformity with the operators operations specifications.

The operative word in the above scenario is proper, IE: that level of instruction that is required for the particular aircraft.

The old saying...garbage in, garbage out, certainly applies.
IF regional airlines continue to operate with reduced levels of crew training, more accidents will surely follow.
Jet transport flying is not new, and the lessons learned so very long ago by the 'oldtimers' apply just as well today, IE: get too slow, when too high, expect big trouble to follow.

Now, having said all this, the US regional airlines flying turbofan equipment have a remarkably good safety record.
Just a bit more FAA oversight is required, I believe, to ensure continued success.

barit1

23rd Jun 2005, 11:15

This is not the first time that an autopilot climb in VS mode has resulted in a stall.

The important message is the while the Pinnacle bird stalled at min GW at FL410, the same thing will happen at lower altitudes & higher GW. Are there no Vmin limits in this mode? What about other types' autopilots?

I have preached for many decades that the more the engineers "Murphy-proof" a system, the more they contribute to raising a new and improved generation of Murphys.

All the more reason for increased AOA awareness; Can't beat raw data.

Elliot Moose

23rd Jun 2005, 11:43

NTSB public hearing webcast (http://ntsb.gov/Events/hearing_sched.htm)

Here is a link to THREE DAYS of public hearings held last week about this crash. Note that these hearings do not happen regularly, but rather only when circumstances are very unusual. As an example, the most recent was AA587 in NYC. This is where all the dirt comes out! If you like courtroom TV, then this is for you!

I am not done day one yet, and already I am engrossed (and I can't stand courtroom TV). Everybody who has posted on this thread should take some time and watch as much as they can. Interesting testimony by Bombardier training as well as Pinnacle's training people!

Enjoy!

AirRabbit

23rd Jun 2005, 21:46

I agree with Mr. Moose -- I watched a couple of hours over the weekend -- and it is riviting -- and everyone here should take some time and watch/listen to what is being said. The NTSB site also has a link to all the documents that were presented. Very interesting stuff there!

AirRabbit

hec7or

23rd Jun 2005, 21:55

The crew here are obviously responsible for the outcome of this unhappy incident, so an element of blame can be fairly laid at their decision to climb to FL410, but their company should have been aware that it was a bit risky. If they were not aware, then they should have been made aware by Bombardier.

I worked for a regional carrier equipped with the CRJ200 and the CRJ700 and the most disappointing aspect of the 200 was that we were promised an aircraft capable of FL410, carrying 50 pax and of flying at M.85!!

It soon became apparent that although it was capable of all three performance targets, it could only do them individually! ie. a full pax load meant FL330 was the max attainable and also left you at max landing weight with only Company minimum fuel at destination.

Since all our pilots were already B737 or BAC1-11 type rated, we mainly just fell over laughing or got annoyed with the Bombardier Company trainers who really rated the CRJ and tried to get us to push the envelope.

In fact, pushing the envelope one day, in order to climb above FL390 to avoid CB activity, and checking with the ICAS2000 FMCthat we could make the altitude!, I got the CONT IGNITION caption and a bit of airframe buffet which led to a curt exchange with Reims ATC which gave me a lower FL after threatening them with a MAYDAY.

What worried me was even after initiating a descent and applying MCT, the bloody aircraft would not accelerate and remained at about M0.686 for nearly 300' until we stabilised level at FL370.

What had caght me out was that the SAT at the commencement of our climb was ISA -2 but by the time we had reached FL390 the SAT had increased to ISA +10 just as you'd expect passing an active weather front, and subsequent review of the performance chart revealed we had climbed about 300' above the CRJ200's service ceiling at our given weight!!

Well didn't I feel stupid.

But not as stupid as my management, who despite reading my ASR and giving me a tea and biscuits, felt that it was a one off.

Could I also add that the QRH for double engine failure does not help the crew make the transition from the windmill relight to the APU assisted relight and it was very common to see crews trying to achieve the rquired N2 during relight below FL130 without realising that they needed to push the start button first!

Although, as 411A points out quite correctly, a lack of experience is an important factor, a lack of training is the major causal criteria and if the Bombardier pilots who trained me are anything to go by, then a lack of experience in their department may also be to blame since they themselves had a mainly ex turboprop (C130 and Beech King Air) or had at best flown heavy jets in the RHS.

So having had the stick shake at FL390 on the CRJ and been ignored when I mentioned it what do you bloody well expect!

chuks

24th Jun 2005, 14:04

Nailed by another lurking vigilante!

Actually, I get to do sim training every six months, just like a real jet pilot. And I try to fly whatever I am handed to the same standards. When I want to have 'fun' with machinery then I use a motorcycle and not a passenger aircraft. Doh!

My point is that the autopilot (in the 328, at least) seems to be loaded with some fairly simple machine logic. Every so often, usually when one is preoccupied with some other task, it decides to use a 30° intercept despite being switched from 'HDG' to 'NAV' mode when just 3° or so off-track. That sort of thing. Usually it gives a nice, smooth capture, which is cool. Then, once in a while it reverts to 'student pilot' mode and takes a big cut, banking first one way and then the other as it attempts to get right on top of the FMS track. God only knows why!

When you get a wobbly localiser signal (not that uncommon in Africa) of course it chases every deviation, where a human would immediately know what the problem is and hold a steady heading while the needle makes like a windscreen wiper.

I don't know about the rest of you but I was certainly told by those held to be more knowledgable to hold the autopilot in fairly high regard, as if it had some higher abilities stuffed inside its dusty interior. Here I am flying with the best equipment ('airline quality' even) I have ever had the privilege to enjoy, and I find it sometimes doing stuff, when left to its own devices, that is distinctly sub-par. Kindly do not extrapolate from that, that I usually follow the 'set and forget' philosophy.

It is arguably a good idea to know what that device will do on its own, without your micro-management of it. You may not always have the time to watch it that closely, such as when dealing with an in-flight problem. So, sometimes when it doesn't matter much, I just turn it loose on its own. Too, 50% of the time there is someone else doing the flying, when I am usually just doing the comms, reading the checklist and watching what transpires.

AirRabbit

25th Jun 2005, 18:46

Hello Mr. hec7or:

I just read your post with great interest – particularly the title of your post and your last sentence. I can’t imagine the frustration you must be feeling right now. Had someone listened to your account, the circumstances leading up to the Pinnacle accident would have been – should have been – avoided. I hope that you’ll take a copy of the Pinnacle accident report and send it to the folks who (from your description) very politely told you to go pound sand – and ask them if they remember your conversation! This business is much too much dependent on accurate and timely information to be able to dismiss such harrowing accounts with polite “chit chat.”

I’m not rated on the CRJ200, but I’m told that the bleed air configuration is pretty complicated and if it is not set up right, restarting an engine would be next to impossible. Another situation that has gone unnoticed for much too long. It’s practical knowledge – borne of experience – such as these accounts that could make the difference between a boring, uneventful repositioning flight, and not coming home to your wife and kids!

I hope that everyone reading this information on this thread takes a moment to evaluate what is heard and recounted, and for the sake of untold numbers of wives and kids, passes it along to their colleagues and anyone / everyone else who will listen! If we can't depend on such information being disseminated through proper channels -- then it must be disseminated through alternate means!

_________
AirRabbit

ZQA297/30

26th Jun 2005, 13:07

Flying at the thin end of the envelope has hidden risks that the certification process does not allow for.

For instance, when I first flew the SJU-GTK-MIA route I was mystified that several times the autothrottle seemed to be having a problem with speed stability. It would sometimes spend several minutes at the high or low end of the normal range just to stay close to target speed.
What I finally deduced was that when the upper winds were strong and out of the West, often there were standing waves way downwind of Hispaniola, and I had been surfing up and down those waves, which were almost parallel to the route.
Now think of an aircraft at max alt, with very little thrust margin left, and throw that type of effect in, and you may have a problem.
At times those standing waves seemed to have the equivalent performance effect of 200/300' per min, but that was subjective judgement.

Willie Everlearn

26th Jun 2005, 22:15

A series of unfortunate events.

There are very few excuses for the crew who flew this particular CRJ on this particular day to this particular altitude and who were unable to relight AT LEAST ONE of the two engines. They should have been able to do that despite switching seats.

According to the Climb capability chart, at 37,800 lbs in ISA conditions they were able FL410. End of story. Anything off ISA and they were out of luck.
Had they flown the aircraft in accordance with the AFM and company SOPs, we wouldn't be discussing this.
Unfortunately, it wasn't ISA at altitude. It was warmer and at that weight the max altitude was lower than 41. Had they checked.

Blame Bombardier? Not their fault.
Blame Bombardier Tech Pubs? The relight procedure is crystal clear in the AOM and QRH. Works well, lasts a long time.
Blame Bombardier Airworthiness/Engineering? Bleed configuration (while awkward) is a no brainer.
Blame Bombardier's Training Center? They didn't train either of these two pilots, FWIW, they didn't train most of the Pinnacle crews.
Blame GE? Both engines were operating fine until someone took the aircraft outside it's performance envelope.
Blame Pinnacle? SOPs are SOPs. Doesn't sound like these two respected, let alone operated, the aircraft in accordance with SOPs. Had they followed SOPs and flown their Company Despatch FPLN to Minney would certainly have ensured there would have been no opportunity to discuss their flight on a public forum.
Blame the FAA GADO/FSDO? Why not? I'm in. Feds get no respect anyway. :E
Blame Flight Safety Memphis? We'll see.
Blame whomever YOU like! If that's what this is all about?

At the end of the day it doesn't sound like either of these two did much to question the climb performance nor the effort it took to get to 41, as the indications would have certainly been there, nor did they even seem to consider the cost of operating off optimum like that. Judging by the result of that decision I'd say that is a moot point.

I've read enough. I've listened to enough. I've drawn my own conclusions.

The ever increasing rush to fill flight decks with minimal/questionable experience levels is only going to see an ever increasing number of these "unfortunate events" as a gaping hole in flight training widens and deepens.

These two individuals, while they may not have known or realized it at the time, role modelled an excellent script for a movie sequel, called DUMB AND DUMBER II.

The one wish I do have out of all this is a genuine wish they'd both survived so they could be despatched to the safety lecture circuit to explain what the HECK they were thinking and what they'd learned!!!
:{

On a more somber note, my heart felt condolences to their survivors.
May God keep and rest their souls.
and...
There, but for the grace of God, go I.

lomapaseo

27th Jun 2005, 12:09

Well Willie, this better not be about blame except for the unimaginative, this discussion ought to be about what it takes to fix it the easiest.

Willie Everlearn

27th Jun 2005, 16:51

lomapaseo

How right you are. :ok:
I had said "Blame whomever YOU like! If that's what this is all about?" This isn't exclusively about blame but blame will definitely be apportioned.

I can only imagine how many pilots out there are pulling these kinds of stunts off on a regular basis out of ignorance. Not just on the CRJ either.
Scary, isn't it? :confused:

There are definitely systemic problems in this disaster. Chiefly, training. What these individuals lacked will surface. I have no doubt.

As a TRI on the CRJ I am appauled by the number of students showing up for training who are so lacking in 'jet aerodynamics' knowledge (to name just one area) it's unbelievable. These people think all they have to do is listen and learn. :{

How do they deal with the things they don't know? Do they not want to use their own initiative to seek out what it is about the things they don't know? Ask questions? Read? Share their experiences?

Perhaps. Perhaps not.
It's easier to BLAME someone else for these shortcomings and deficiencies. :sad:
Not that it should be news either.

You can bet the NTSB will have a lot to say about regional airline and training center cirriculum when this investigation is over. We might even see a change in those FAA written exams if all goes according to Hoyle.
Maybe it's time to do some actual learning instead of memorizing answers from some huge database.
The knowledge otherwise gained might come in handy on a dark and dreary night.

Maybe that's a good thing. :ok:

lomapaseo

27th Jun 2005, 23:23

Willie

I agree:ok:

Now what's it going to take to drive this discussion and the near miss at Boston in the direction of working a fix with the avialble resources and infra structure. We sure as hell can't afford the time it takes to change plane manufacturers,governments and national flags to solve aviation disasters.:sad:

westhawk

28th Jun 2005, 06:57

Mr. Air rabbit,

After reviewing the documents most pertinent to this occurance, perhaps you will be willing to share your reaction to the facts as they are presently available for everyone to see.

http://www.ntsb.gov/Events/2005/Pinnacle/exhibits/default.htm

The NTSB will release it's opinion of these facts in due course. Barring any radical revisions to the current state of the facts, most of the story is clear enough to draw a few conclusions. The only unresolved questions relate to the events following the stall. Namely, to find the precise reason why an airstart was not successful on at least one of the engines. The right engine overtemped so severely (FDR data) that it may indeed have been locked up due to thermal damage and incapable of running. I did not find any indication that the examination of either engine has been completed. Is core-lock phenominon (sudden cooling causing a loss of operating clearances) a factor which explains why the left engine was not restarted? This is being investigated. Or did the extreme stress and time pressure of this situation lead to a crew failure to properly configure the bleed system to attempt a start on the left engine? It would be handy information to have in case this scenario (dual engine failure) ever occurs again, perhaps as the result of encountering CAT, wake or aggressive maneuvering to avoid collision. The parties to the investigation must be very interested in this question. I know that I am.

If commenting on the implications made by the currently available facts offends, that is a shame. As for the effect that "seeing pilots villified" may have on up-and-coming pilots, sometimes the facts are unpleasant but that is not a good reason to attempt to censor it by using indirect references to chide others. Please be forthright and speak clearly to make your point, whatever it might be. There are several valuable lessons to be learned here. The real utility of sites like this one is that it provides an open forum for reasoned discussion and exchange of ideas. Or to let off steam! While I agree that rampant and uninformed speculation is certainly not appropriate, discussing the implications raised by the published facts certainly is. So is commenting on the poor taste exhibited by Pinnacle management when they denied any responsibility for the crash by putting ALL of the blame on the crew and none on themselves in public statements. Perfectly understandable from a business standpoint, but still not very laudable, to say the least.

Best regards,

Westhawk

catch 22

1st Jul 2005, 07:38

I wonder if by 'firewalling' the thrust levers they severely damaged the engines. I understand it is not (Pinnacle) company policy to 'firewall' but in my experience with pilots from US carriers this is commonly taught. I recall one incident when an aircraft stalled in holding at 20,000 feet. By firewalling they ruined a few of the engines. If there is a possiblity of ground contact - sure. It is all about risk/reward. But at high altitude......

barit1

1st Jul 2005, 11:26

Firewalling throttles (oops, thrust levers...) should not cause short-term damage to modern engines - the acceleration fuel schedule is computed irrespective of throttle position in all fuel controls that I've worked on for the last (expletive deleted) years.

Granted, this technique may not be the best for long-term performance preservation (fuel burn, turbine temp. margin), so the accountants may not like it - so if that's an accountant sitting next to you - :}

RRAAMJET

1st Jul 2005, 12:56

Barit1 - I can absolutely assure you that on the MD-82/83 series of 'modern' airliners if you slam the throttles you probably will do some blade distortion or overtemp. That's because the pathetic JT8D-217/219's have ancient hydro-mechanical fuel control mated to their 'modern' engines, with no limiters. MD ran out of development money to truly modernise their creation back in '81, leaving just a souped-up DC-9.

But, agreed, on the RJ with FADEC, probably not.

Mad (Flt) Scientist

1st Jul 2005, 14:16

CRJ200s do NOT have FADECS. The engines are hydromechanically controlled and it is very possible to cause engine damage if you simply push the throttles as far forward as they will go. The maximum thrust rating for a given condition is set by moving the throttles to achieve a specific N1 value, which usually does not correspond to maximum throttle travel. At any point beyond that, you're exceeding the cleared engine operating envelope, and introducing a risk of engine damage of various degrees.

lomapaseo

1st Jul 2005, 18:56

I can absolutely assure you that on the MD-82/83 series of 'modern' airliners if you slam the throttles you probably will do some blade distortion or overtemp. That's because the pathetic JT8D-217/219's have ancient hydro-mechanical fuel control mated to their 'modern' engines, with no limiters. MD ran out of development money to truly modernise their creation back in '81, leaving just a souped-up DC-9.

But, agreed, on the RJ with FADEC, probably not.

the last I knew was that the MD-82/83 was certified to an "R" or reserve thrust rating which automatically kicked the thrust up to an overboost when it sensed a drop in EPR on the other engine.

By certify it means that no damage will occur to the engine.

To my knowledge most hydro-mechanical controls do have limiters such as RPM, pressure and in some rare cases temperature to restrict the engine from blowing itself up..

It is indeed hard to imagine how you can command over-meter fuel to an engine that hasn't even started yet.

Of course you can still burn out the turbine with min fuel flow simply by starving the burner of pressurized air.

westhawk

1st Jul 2005, 20:45

It is also possible that with climb thrust set, that stall induced turbulent airflow at the engine inlet(s) could cause a rapid rise in ITT exceeding the maximum limit. I am not familiar enough with the CF-34 engine control system to know whether it has a temperature limiting device capable of limiting a rapid ITT rise. I recall that it does have some kind of limited electronic engine control unit that takes effect at higher N1 speeds. Perhaps someone with the technical manuals could comment.

I have noted during my simulator training on two bizjet types that both of the major training providers teach the "firewall the levers" method for stall recovery and go-around/missed approach maneuvers. Unlike the real airplanes in the fleet, the sim will not overtemp/overspeed. In aircraft equipped with DEECs or FADECs, this will not harm the engines because the modern digital engine control will simply set max thrust very precisely while observing limits. However, on the aircraft I currently fly, this is a really bad idea. Very large exceedences are possible if you apply "radar power"! The older analog EECs do not anticipate limits. They do not act to limit ITT or RPM until after limits have been exceeded. During a rapid change of engine speed, the limits can easily be grossly exceeded just like they can on the purely hydro-mechanically controlled engines. I have mentioned this to the instructors and managers at the TCs. I was informed that this is the method they are required to teach. I don't know why. So I go with the flow at training and operate the real engines with greater care than they advocate. I guess it is another case of what looks good on paper versus the real world!

Best,

Westhawk

AirRabbit

2nd Jul 2005, 06:02

Mr. Westhawk (et al):

Methinks ye may have read too much into my earlier post. I was not, in any way, chiding you – quite the contrary – my sincere compliment was directed toward all who seemed to have a more professional approach to the circumstances and media “buzz” surrounding a post-accident inquiry such as this – and particularly to yourself! If you misunderstood my attempt to compliment you, I apologize.

I completely agree with you about the utility of forums such as these! It is my opinion that you and I do not disagree on the value of post-accident discussions -- and any disagreement that may exist (or come to light) is very likely to be almost exclusively due to my past experiences – which, as I’ve indicated, have not always been what professionals would desire. As a result, I am, and I’ll probably continue to be, very cautious when leaping into discussions about post-accident information that “leaks” out or is published as preliminary findings. Please understand, when the facts are that a pilot has screwed up, you’ll not find me trying to white wash the concept. But I do hope that in my comments about such a pilot one would not find my focus on the fact that he screwed up, but rather would find my focus on what can be learned so that other pilots will be less likely to find themselves in similar circumstances and prone to make the same mistakes.

Please understand, I am not offended, at all, by examining the evidence and following it wherever it leads. What I was cautioning against, and what I will continue to caution against, is that we don’t jump to conclusions or attempt to find justification for preconceived opinions. My overall impression is that this occurrence developed because two pilots decided, for whatever reason, to abandon their normal operating procedures – and one could certainly surmise that this was done because, in their eyes, “the rules are relaxed when we don’t have passengers aboard.” They apparently elected to use the autopilot climb rate rather than speed (airspeed or mach – I don’t know the autopilot setup in the CRJ). Both crewmembers seemed to recognize that this was a “non-routine” event, decided upon to “have some fun.” Had they elected to use the speed mode, there is a chance that they would have realized that FL410 was beyond the airplane’s capability that night. And, after reaching FL410, the Captain left the cockpit and the F/O apparently didn’t believe it necessary to don his O2 mask. Was this a symptom of the “relaxed rules” thinking? Both pilots apparently recognized what was an “unusually high pitch attitude.” They both apparently realized that their airspeed was slow and getting slower. They both apparently recognized that they were not going to be able to sustain that altitude. I’m not at all sure what other clues may have been necessary to suggest to them that they were where they shouldn’t be and that they should do something about it – right now.

However, whatever clues may have been available were not used and the problems began. What about them? At first look, it would seem that a lot, quite a lot perhaps, and some would say virtually all, of the information necessary has been obtained and all that is left is the sifting of that information and reaching a conclusion. My experience has shown that very often it seems that some of the most pertinent questions go unasked – and therefore unanswered. It is also my opinion that in at least some circumstances an observer’s opinion of the situation may well color the observation being made. For example: looking at the FDR traces and reading the narrative that accompanies those traces – it would appear that the investigator has concluded that after the stick shaker activated, followed by the stick pusher firing, one of the pilots pulled the control column with a force calculated to be 25 pounds and then released the control pressure.

The questions that I would have thought should have been raised during the discussion that led up to this statement would have been the following:
1) Other than pilot action, what could cause the autopilot to disconnect?
2) If there were no pilot intervention, would the stick shaker activation electrically disconnect the autopilot?
3) If not, would the stick pusher activation electrically disconnect the autopilot?
4) If not, would the stick pusher cause physical pressure on the control column that would override the autopilot and result in a “brute-force” disconnect of the autopilot?
5) Does the stick pusher provide a forward control column movement to a specific attitude, to an angle of attack, or to some other parameter?
6) At what point does the stick pusher disconnect?
7) If there were no pilot intervention, given that the autopilot may have been disconnected because of an overpowering of the pitch attitude to which the autopilot had trimmed the airplane, what would be the expected reaction of the airplane upon stick pusher release?
8) If, upon stick pusher release, would it be expected that the airplane would attempt to return to the previously trimmed condition?
9) If so, would this physically move the control column?
10) If the control column would be expected to move, what would be the recorded movement and could that be interpreted to be a 25-pound pull on the control column?
11) What would be the effect of decaying airspeed on any tendency to return to a previously trimmed flight condition?
12) If there were no pilot intervention, what would be the expected short term response of the airplane?

A second series of questions that might have been asked might have included the following:
1) During training for recoveries from approaches to stall, in those circumstances where the pilot allowed the stick pusher to fire, what were the tendencies of that pilot during and immediately after the stick pusher activation? In other words, was the pilot attempting to dampen the stick pusher input during its input? And if so, what did the pilot do with the controls when the stick pusher deactivated?
2) If the pilot was actively pulling on the controls during stick pusher activation, did the pilot tend to over-control the pitch when the stick pusher deactivated?
3) If so, did the pilot tend to enter a secondary stall / stick pusher event?
4) If so, did the pilot attempt to dampen the second stick pusher input – as he did initially?
5) If so, what were any continuing actions between the pilot, the stick pusher, and the pitch attitude?

I see no evidence that these, or similar questions, were asked/answered nor do I see any information provided to understand that this information was made available. Prudence, I would have thought, would have required these answers or, at least, a discussion of this information would have been necessary to enlighten the on-going investigation. I say this because it would appear, from investigator statements, that a phugoid-type of oscillation occurred.

This airplane has a particularly disagreeable tendency to “dutch-roll” (rather significantly I might add) when the yaw damper is disengaged – and this is particularly true at higher altitudes.
With the loss of electrical power (when the engines failed) did the yaw damper control disengage? If so, was it ever re-engaged? If not, did a “dutch-roll” develop?

In talking with several persons close to the investigation, I understand that a careful analysis was made of the number of times a bleed-air re-configuration was made during the futile attempts to start one or both of the engines. I understand this configuration was changed some 16 times by one or both of the crew. I also understand from persons knowledgeable about the CRJ200, that while not an overly complex panel, if just a single error was made in that configuration, it would be unlikely that someone would have been able to retrace the selections made to negate the initial error.

In my very brief review of the “core lock” phenomena, I wasn’t able to fully digest the causes and/or if there were any in-flight resolutions to that particular problem. I believe that it is, at least, noteworthy, and perhaps worthy of more scrutiny, to recognize that it was apparently a routine practice that engines undergo “core lock” testing before being shipped. I would think that someone would want to ensure that a correction to eliminate that potential would be appropriate prior to releasing such an engine for revenue service.

In reviewing the transcript of the CVR, it seems to me that the Captain was content to let the F/O continue to fly for quite a while. Later, when he decided to take control, it appears that he was about to deal with an emotional situation that was likely to result in losing his F/O from conscious participation; and I believe the Captain did quite a nice job of returning that F/O to the job at hand without spending unnecessarily long in the process.

It sounded to me like the primary concern of the Captain was getting the engine to start – and because of that focus, the focus of the F/O was directed largely to that end as well. He seemed to be riveted on that problem – almost to the exclusion of the flight status of the airplane (where they were headed, the rate of descent, etc.). In fact, it seems to me that he was so intent on getting the engine started that he was willing, saying so on a couple of occasions, to trade altitude for airspeed to wind mill the engine to facilitate a start.

So, is it training? Should the airline have provided high altitude simulator training? Should all airlines do this? I am under the impression that the FAA Flight Standardization Board Report on the CRJ200 did discuss recommended training or familiarity (I haven’t read the report) with high altitude operations, specifically regarding the tendencies for dutch-roll, and I believe it referenced the complexity of the bleed air control panel for engine starting. Perhaps it is past time that the FAA make that report a regulatory requirement instead of a set of recommendations that may or may not be heeded by the industry. Should simulators be qualified only after demonstrating that they do, in fact, perform and handle at high altitudes, just like they do at intermediate and lower altitudes? Should we begin training crewmembers on recovery from stalls rather than training on recovery from approaches to stall? Should we require each crewmember to understand the power-off glide ratio of his/her airplane and practice dead-stick approaches from above FL400 in the simulator? Do we require direct reading AOA indicators in commercial airliners? Do we go back and review each ground training program for its inclusion of high altitude operations and the effects of temperature inversions, lapse rates, density altitude, service ceilings, etc.?

It is almost easy to answer in the affirmative to most if not all of the questions here. But I recognize that training is an expensive effort, particularly today. Airlines are not rolling in money – they must spend it wisely. Training is always “on the bubble;” and it is primarily because of the costs involved in training. Should the regulator step in and mandate these things – regardless of the cost? The arguments on both sides are substantial – and what usually results is an attempt to find a happy medium between the two opposing points. However, it is my experience that in doing so, there is rarely any “happy” and almost never a “medium.”

I recognize that I have only raised a lot of questions and haven’t really taken on the answers to many of them. Its not that I can’t or won’t. It’s just that this post is already much too long. I don’t have any problem with providing anyone here with my opinion of what the answers to some of those questions should be – but I’ll wait to see if anyone is really interested in hearing any more of what I may have to say. Until then, I’ve probably said enough – at least for now.

________
AirRabbit

westhawk

2nd Jul 2005, 08:38

AirRabbit,

Thank you for your well considered reply. I can see by the questions you still have that you have given this matter quite a bit of study and thought. My apologies for misunderstanding your intended meaning in your earlier comments.

Those FDR traces would sure be easier to interpret if I could line them all up in parallel on a very large screen! At least one important step remaining to be completed is the analysis section of the final report. But alas, we will probably have to wait another year for the final report. Based upon my reading of past major investigation reports, I think that is the most likely place to see your questions addressed if indeed they ever are. I feel fairly confident that the events leading to the stall are pretty clearly described by the FDR and CVR data, making it possible to reach a few conclusions and find some lessons learned in the flight up to this point. These lessons related to general airmanship and aeronautical knowledge have been discussed in several posts. No need to repeat them.

As an aside, I would like to share my personal observations on the performance of the autopilot when coupled to the F/D while it is selected to IAS or mach hold. (to include FLC in Honeywell integrated EFIS systems.) In the Collins and Honeywell equipped aircraft I have flown, when these speed hold modes are used, there is a distinct tendancy for the aircraft to "pitch hunt". To avoid having to tolerate this condition of constant pitch changes, I and most pilots I have flown with prefer to climb these aircraft in VS mode since it results in a more consistent pitch attitude. It is a little bit more work to closely monitor the speed and occasionally adjust the desired vertical rate to stay on speed schedule, but it's worth it. Once you are in the habit, it works very smoothly. I do not know if this tendancy is common in the CRJ as I have not flown one. Maybe a CRJ pilot could comment.

It is the events following the first indication of aerodynamic stall that I find require further analysis for me to understand what took place from this point on and how this knowledge might be applied to benefit other pilots facing similar circumstances. It is clear that once the descent began, they were under a lot of pressure to find their "A" game and right soon! From this point in the sequence, the events should be analyzed without regard to how they got into this mess, since the next crew to face this situation could find themselves there as the result of a completely different cause like turbulence, etc.... GE data provided to the board indicate that in all documented tests, "core-lock" was overcome by torque from the starter when used. I hope this is proved to be the case.

Time to hang it up for now. Gotta fly in the morning.

Best regards,

Westhawk

AirRabbit

3rd Jul 2005, 18:59

Howdy Westhawk –

I read your comments on the function of the autopilot’s tendency to “pitch hunt;” and I certainly agree that this is a most disconcerting and uncomfortable action that most pilots, including me, would want to avoid. That may well be the reason these guys chose the mode of operation they chose – but, as you pointed out, it’s “more work to closely monitor the speed.” The part that I think these guys missed is the “…occasionally adjust the desired vertical rate to stay on speed schedule” and, I believe that is because of the attitude they adopted that “the rules are relaxed when we don’t have passengers aboard.”

However, having said all that – I completely agree with you that it is important to know what happened after the aircraft was allowed to get into the sick shaker / stick pusher realm of operation. The material that is available on the FDR, as informative as it is, could be a lot more informative if the questions I’ve suggested were asked and answered. I fear that the reason these or similar questions were not asked and answered, is that someone (perhaps several someones) with some degree of authority (and in my book, that is what is important), concluded that the FDR and CVR data was singularly sufficient to reach the necessary conclusion(s).

I reiterate, without the additional information that could have been supplied by answering those questions (or similar ones), the conclusions reached, at the very least, have an opportunity to be less than fully developed. IF that is an accurate position (and obviously I believe it is) then the conclusions reached – any and all conclusion regarding this portion of the accident profile – is going to be, at best, incomplete – and, I believe, very likely to be misleading to a very deserving and perhaps due to this, still vulnerable, aviation industry. I don’t understand an attitude that would allow this to occur. And this potential is the basis that formed my earlier admonitions to be sure that ALL of the facts were considered before reaching conclusions.

The point is that the crew may very well have done exactly what the synopsis of the investigators indicates; and there may be no additional areas of “fault” that came into play. However, unless some additional information is gathered and considered as to whether or not the airplane itself played a more substantial role in this tragedy, we may be wrongly blaming only the crew (certainly their family, friends, and co-workers have enough to occupy their minds without having to endure additional accusations, particularly if incorrect) and ignorantly allowing a potential problem with a machine continue to lurk in the darkness of that ignorance, awaiting an opportunity to spring to light, this time with a full load of passengers!

I guess we’ll all have to wait, see, and pray.
_______
AirRabbit

armada

4th Jul 2005, 14:49

Related somewhat. This is Air Canada Jazz

on Thursday June 9th one of the new model CRJ-705s being flown by Jazz Air between Houston and Calgary had a stick shaker incident near Colorado Springs. The aircraft (C-GJAZ) was at FL410 and was at Mach 0.70 when the flight encountered a downdraft and the stick shaker activated. Maximum thrust was set and a lower altitude was requested. The airplane descended at approximately 1000 fee per minute with a 3 degree nose down attitude. An attempt to recover at flight levbel 4000 was made but the stick shaker activated briefly and the descent was continued. Recovery was made at flight level 380 and the airplane returned to a planned speed of Mach 0.77. There were 62 passengers on board and no injures were reported. The Transportation Safety Board of Canada has secured the flight data recorder and has provided an accreditted representative to the investigation. The NTSB will be conducting the prime investigation since it happened over U.S. airspace.

barit1

4th Jul 2005, 17:05

A remarkably similar event occurred the following day: 10 June (http://www.ntsb.gov/ntsb/brief.asp?ev_id=20050616X00790&key=1)

(If that link fails, search on the www.ntsb.gov site for document
DCA05WA073 )

411A

4th Jul 2005, 17:11

An interesting item, armada.
It would indeed appear that a few junior jet guys are not paying attention.
Wonder just when these few will actually wake up?

westhawk

5th Jul 2005, 04:09

Glad nobody was crossing below them, Armada. Flying NW bound near Co springs like that can leave you stuck in the descending side of a rockies wave for a while. Bad deal without much excess performance to play with. My friends who fly Challengers have commented that the CF-34s really peter out above FL370. It's no Gulfstream or Lear and the wave around there can get pretty strong. Glad things worked out OK.

Best,

Westhawk

Willie Everlearn

5th Jul 2005, 10:32

If I may pass along something else to consider....

There are at least three different CF34s on the various Challengers.

The CF34s on the RJ 100s and 200s are different from one another.

and,

The CF34 on the 700 and 900 series are different again to those on the 100s and 200s.

barit1

5th Jul 2005, 12:25

Good point about CF34's - the dash 3 (RJ100 & 200) is closely derived from the military TF34 - designed in the late 60's. It has 14 HP compressor stages, and 2 HP turbine stages.

The dash 8 (RJ700 & 900) is a fresh design with little commonality to earlier models. Improved aero design yields 9 HP compressor stages, 1 HP turbine stage. The LP system is all-new too.

The dash 10 (EMBRAER 190/195) is yet another go.

DA50driver

5th Jul 2005, 14:34

What is the typical total time for the crews involved in these incidents? I am a corporate pilot, and all of these mishaps occured back in the 60's with Lear-jets in our end of the business.

Do the airlines teach high altitude aerodynamics at all, or do you put a turboprop guy in as PIC without much training? All of these things have happened before, history is being repeated. It is not magic up there. Keep your speed up, and you will be fine. I would soil my shorts if I was doing .70 at 410.

barit1

5th Jul 2005, 15:18

You mean there's no AOA on your LCD????:sad:

B738

5th Jul 2005, 16:50

Some answers to the questions from Airrabbit:,

As soon as the stickshaker activates the autopilot will be disconnect automatically. Also the continuous ignition will come on!
To silence the tone of the autopilot disconnect you have to push the "Autopilot - Stickpusher- disconnect putton" on the control wheel. When you push this button the Stickpusher is deactivated for the time till the button is released!

Willie Everlearn

5th Jul 2005, 23:57

If I may add the following comments?
:sad:

"As soon as the stickshaker activates the autopilot will be disconnected automatically. Also the continuous ignition will come on!"

Not quite. But, I know what you mean.
Continuous Ignition commences prior to and in advance of, stick shaker as does the EICAS status message CONT IGN. If either pilot hasn't selected continuous ignition, for a reason, this event is likely telling him/her something isn't normal.

Activation of the stick shaker DOES disconnect the auto pilot and cancellation of the cavalry charge is left to either crewmember.
The way the auto pilot disconnect works in the RJ, is this. If either crew member disconnects the auto pilot, the cavalry charge is heard three times. If the autopilot disconnects by itself, for any other reason, the cavalry charge is continuous until either crew member presses the disconnect button on the control wheel.
:ok:

"What is the typical total time for the crews involved in these incidents?"

Crew total time varies from pilot to pilot. Period.
There is no monopoly on smarts, knowledge or ability because of total time. Dozing off during flight, reading the Swimsuit issue or newspaper doesn't automatically make you an experienced pilot. No matter how many hours you have. It merely depends on what you did during the time you acquired those hours.

But. The average Regional Airline Captain showing up for RJ training and RJ Type Rating has 15,000 hr, approximately. As most have been flying Saab 340, Jetstream 31/41, Dash 8 and Brasilia aircraft. Some have even flown BAe146s, EMB 135/145s, F28s and F100s.

In my experience, many have also been affected by their company choosing to replace the B737s or A320s they've been flying. So, it's difficult to pigeon hole the Regional pilot.

"I would soil my shorts if I was doing .70 at 410."
:{

How would you feel about 0.57 Mach??? Like these guys.
Well, the truth be known. Many RJ operators have the conviction that the only way to climb this aircraft is in vertical speed for PAX comfort. Unfortunately, the people who know better decided to publish climb speed profiles for the CRJ and it happens to be 290/.70. To date, I can't recall any of the jet aircraft I've flown having a vertical speed profile. I DO recall in most, a caution about a reduction in vertical climb capability on the order of "less than 300 feet a minute" being of significance. RJ students are taught to climb in IAS to Mach crossover and when V/S decreases below 500 fpm, heads up!!!

Funny things can happen when your are off the climb speed profile and trying to "zoom" climb to 41. But let it be said, there is no guarantee to an unwary crew who zoom climbs or V/S climbs to an altitude that may be just beyond aircraft weight vs thrust ability.

"do you put a turboprop guy in as PIC without much training"

These pilots receive sufficient training, for sure.
They are taught to fly the numbers. They are taught where to find the numbers. They are also taught to follow SOPs. When these edics are followed, success results. When they are not...it's up to the flying gods to decide.

But, who's to say what any pilot needs beyond the basic RJ cirriculum, especially when he/she is rarely vocal about what they lack or don't know about high altitude flying.
Isn't that an embarassing dilema for most of us? Human nature, being what it is and all?!

As an RJ Type Rating Instructor it's a tough one to call as the "approved" simulator training syllabus is suppose to cover the widest range of average pilot experience, knowledge and ability immaginable.

Looks like somebody got it wrong. :sad:

Ignition Override

6th Jul 2005, 04:19

Are the Bean Counters (where cost accounting is "the church altar") a major problem regarding training costs and training " footprints (length)" at Pinnacle and many other companies?

Until less than nine years ago or so, at least one US major airline had no desk top computer training aids to allow a pilot to prepare in advance for an 0500 brief with a very rushed 0600-1000 fixed based training on the B-757. Its 'training cost managers' finally justified the expense to develop computer-based training aids which allowed pilots to better understand and prepare for training on their very first FMC aircraft, and allow that fleet's training equipment to finally catch up with that of some other US airlines. And the company's First Officers each had about 7,000 hours flying or more (CV-580, 727..), never mind the even more experienced captains. But these hours do you no good when you struggle to keep your head above water in an over-compressed, very rushed training syllabus learning an entirely new concept of c0ckp1t management. A different fleet has probably the very best training program, even several years ago.

If bean counters can create such handicaps with one US major airline (some FOs had previously spent their own money on an FMC course at Boeing, reportedly about $5,000 each, being well aware of how inadequate their airline's syllabus was; their classmates were baffled that a few guys could grasp the concepts and relax a bit each day after class, without day after day of confusion and humiliation), then what about an operation where new-hire FOs sometimes have very little experience (partly because there is no per diem nor pitiful paycheck for about five weeks)? Some apparently have very little instrument and no swept-wing backgrounds, based upon what two CRJ Check Airmen told me (at DTW and DFW). One had reportedly finished the famous (or infamous?) Gulfstream program in Florida but still had an inadequate instrument flying background, from what I was told, after paying so many thousands of hard-earned dollars and flying as FO on a B-1900 turboprop, mostly in VMC :sad: .

AirRabbit

7th Jul 2005, 16:11

Hey B738 –

Thanks for the information. A question back to you … Do I understand correctly, that if you push the A/P disconnect to silence “the cavalry” charge, as someone else posted here (BTW, I like that description), the stick pusher will not activate as long as you keep the disconnect button depressed? And does that mean that when the button is released, the stick pusher will fire if the pitch attitude or AOA has not changed?

I would suspect that nothing will happen to the longitudinal trim (which the A/P would have probably trimmed right up to the point of A/P disconnect) and I would suspect that if either the crew or the stick pusher got the nose down (not sure what triggers stick pusher deactivation) any airspeed increase above where the trim was last effective would result in some sort of nose-up pitch. Is that accurate?
_______
AirRabbit

B738

7th Jul 2005, 18:34

Hello,

Willie thanks for the detailed explanation, I had not so much time to descripe it in such a detail...

@AirRabbit
"Do I understand correctly, that if you push the A/P disconnect to silence “the cavalry” charge, as someone else posted here (BTW, I like that description), the stick pusher will not activate as long as you keep the disconnect button depressed? And does that mean that when the button is released, the stick pusher will fire if the pitch attitude or AOA has not changed?"

The stickpusher will not activate as longs as you press the button. When you release it, the stick pusher will fire.
On the first flight of the day, you have to do a "Stall-test" where the Stickshaker and pusher is activated on ground. When the stickpusher is fired and you press the A/P-disconnect button, the Stickpusher is immediately deactivated. When you release the button the pusher is activated again.

Willie Everlearn

7th Jul 2005, 20:18

The SPS test, while on the ground, is an integrity test of the SPC system. The auto pilot is not engaged whilst doing this test (with most CRJ operators). Pushing the (red) AP Disc button on the yoke, causes the pusher to "push" the stick forward as it is designed to do.
:confused:

I'd be surprised if holding in the AP Disc button during a pusher event, prevents the pusher from doing it's thing.

But I'll try it and get back to you.
:ok:

AirRabbit

8th Jul 2005, 22:47

Hey Willie / B738:

Thank you both for the replies. And, while I'd like to learn a little more about how the shaker/pusher operates on the CRJ, please don't do something that has the potential of getting you or the airplane into trouble -- my thirst for knowledge ain't that big!
_______
AirRabbit

B738

9th Jul 2005, 17:16

Hello,

@ Willie:

I'd be surprised if holding in the AP Disc button during a pusher event, prevents the pusher from doing it's thing.

But I'll try it and get back to you.

An extract of the pilot reference manual CRJ200:

Stick Pusher Disconnect Features:

The stall protection computer monitors the rate of change of the AOA vane to determine when to disconnect the stick pusher.

The stick pusher can be stopped by pressing and holding either the pilot's or copilot's control wheel autopilot/stick pusher disconnect switch (AP/SP DISC). The stick pusher is capable of operating immediately when the AP/SP DISC swith is released.

Should the SPS incorrectly activate the stick pusher, the stick pusher my be disabled by selecting eigher STALL PTCT PUSHER switch to OFF at the pilot's or copilot's stall protection panel. Both switsches must bei ON for stick pusher activation.

aardvark2zz

9th Jul 2005, 22:16

I made a little summary of part of the flight starting after the power came back on.

After the power came back online, until end-of-flight.

N1 for both engines was spooling down.
N2 for both engines were stuck at 0 (see Note).
ITT for both engines were decreasining and took a long time to reach 90C.
FF for both engines were stuck at 0 (see Note).
Air Speeds were way below 235 knots (IAS!?).
APU bleed valve opened around 13000 ft.

I didn't see much in terms of where this bleed air was going; i.e. right or left engine.

Note: on some graphs we don't see one of the lines at all.

westhawk

10th Jul 2005, 06:14

Regardless of what altitude the AFM or FMS predicts the airplane is capable of achieving at a given WAT, they do not account for unanticipated atmospheric conditions such as mountain wave, CAT or warmer than predicted (the temps entered in the FMS or used on the perf chart.) temperatures. If any of these conditions are encountered, then it will be important that the crew recognize the degraded performance and act appropriately. There comes a point in this scenario of declining speed (VS mode) or ROC (IAS,MACH or FLC mode) when defeat must be admitted! Time to level off or if getting really slow, descend. Will FLC descend to remain on speed? Airplane performance charts are done as part of certification and are intended to provide a means of performance planning. They guarantee nothing if the conditions are different than stated. You make your plan based upon the available information and then see how it goes. The ASI and VSI will let you know how it is going. The OAT, TAT, RAT or SAT will help you recognize whether temperature is the culprit. AOA can be used to crosscheck the speed trend. All of these things are available to jet pilots (depends which jet) for good reason. It is up to pilots to observe airplane performance closely and be careful what we believe. Always view AFM or FMS predicted performance as possibilities not yet proven. Show me! It is also better to let ATC in on your predicament earlier rather than later.

The above words might just as well have been written before the occurances being discussed on this thread. The lessons were learned because they came up as a natural consequence of flying moderate (some might say weak performers!) performance jets. I have little interest in magazines or crosswords while in flight. I do however enjoy watching all the little dials and indicators and such. I used to think all pilots did. Another useful lesson learned. (cool pilots read magazines) I guess my natural curiosity and interest pleases me at least. When it doesn't, I'll work for Wyvern or FAA. 9 to five baby! But not just yet.

Best to all,

Westhawk

hec7or

10th Jul 2005, 15:02

Can anyone tell me whether the starter button was pressed at all during the starter assisted relight procedure in this incident?

I seem to remember the QRH goes straight from windmill relight to APU assisted relight but doesn't highlight the subtle differences between the two procedures.

My observations in the sim were that approximately 75% of crews would need to repeat this exercise due to an inability to achieve the required N2 RPM during the starter assisted relight procedure because the QRH gave the impression that you needed at least 15% N2 prior to operating the starter button because this limit was written adjacent to the 90 degree ITT limit which you did indeed have to achieve before moving the start/thrust lever.

You would only get the 15% N2 after selecting start, a point the majority of crews failed to realise. The crucial difference being that the limits apply prior to initiating a windmill start but mainly only apply after an assisted start is initiated but before the start lever is moved.

We didn't see this as a major issue however as we considered a double engine flameout highly unlikely!!

Our management were reluctant to prescribe to captains an altitude limit and our flightplans were always giving cruise altitudes of FL360 and FL370 regardless of performance capability and the existance of an optimum FL was never discussed during briefings, the general perception being higher is better.

With this level of ignorance within the management and line pilot communities we were very fortunate not to have a similar incident.

Beanbag

11th Jul 2005, 09:29

Ignorant question from an ex-PPL: does no-one find it surprising that they don't seem to have started planning a landing until below 13000'? I'd have expected them to estabish a clear plan to get down safely without engines right at the start of the incident, expecting to change it when they restarted the engines.

411A

11th Jul 2005, 11:23

<<Our management were reluctant to prescribe to captains an altitude limit and our flightplans were always giving cruise altitudes of FL360 and FL370 regardless of performance capability and the existance of an optimum FL was never discussed during briefings, the general perception being higher is better.

With this level of ignorance within the management and line pilot communities we were very fortunate not to have a similar incident.>>

I personally find this not at all surprising, Hec7or, as many new guys to jet transport flying, never having been informed about all this, would tend to agree with the idea that 'the computer knows all' and no logical thought process is generally required.

Years ago, before computers (and the magic boxes they come in) the lessons learned the hard way about potential problems that do indeed occur at higher altitudes with swept wing jet transports resultes in a few accidents that were not pretty.

Now, many of these older guys in management/line flying have long ago retired, and the replacements think that they simply 'know better'.

This very unfortunate accident sadly proves that simply do NOT.

barit1

11th Jul 2005, 12:55

...many new guys to jet transport flying, never having been informed about all this, would tend to agree with the idea that 'the computer knows all' and no logical thought process is generally required.

The computer knows only when it's been programmed to know. It is POSSIBLE to give it the smarts to provide a margin for an unstable air mass (SAT creep) and other anomalies.

But that would just contribute to a further "dumbing down" of the newbies, IMHO.

Willie Everlearn

12th Jul 2005, 02:03

hec7or

As a sim instructor on this aeroplane, let me say that I fully agree with your remark about the confusion induced by the relight procedure. When a crew has been insufficiently briefed before conducting this event in the FFS, it's a cluster f**k.
I always try to stress the importance of clearly understanding the QRH checklist and its' relevance to crew survival on a cold, dark and dreary night whilst running out of airspeed, altitude and ideas. Most students are quick to point out that their company does not provide individual crew members with a QRH of their own. Pity.
(Make way for the LCC.) :confused:
Therefore, they NEED to know, that the core windmilling rpm drops to approximately 3%, give or take, even with the fan turning at 20 + %!!!
The QRH also points out "WHEN ENGINE ROTATION IS ESTABLISHED". This can only be met, IF the crew drops the nose at 26,000 feet and accelerates "to 300 KIAS or greater to achieve the required N2" as informed." Which this crew did not manage to do. :(
Did they not realize N2 is what governs engine starts??? Were they looking at N1 perhaps and deciding well enough? I surely wouldn't know.
The ITT must be below 90 C and the core (N2) spinning at at least 12% above 15,000 and at least 9% below 15,000. ITT reduction is generally not a factor when the aircraft has already descended from 41 to 21. But, here's the rub.
The QRH Engine Failure checklist ALSO states "if neither engine is restarted: consider a forced landing or ditching." So, at what point to abandon the start attempts? I teach that following the initial attempts to look at RPMs. Core N2 zero, you've got engine damage because they should be turning. The one that IS, should be concentrated on. Were both engines on the accident aircraft turning or not turning? That is the question.

Beanbag

How right you are.
In the clear light of day, it seems your suggestion is spot on. Unfortunately, in the clouded reality of "Holy Sh*t", some of the balls get dropped. Perhaps this is part of what happened to this crew. The hearing pointed out that there were three useable airports short of Jefferson City the crew could have accepted.
What can I say? It was their call.

et al

It surprises me to watch Human Factors at work in the sim.
We hammer these crews with SOP, SOP, SOP!!! To the point where the strictest adherence to SOPs during an emergency are more of a distraction than a solution. In some cases, you have to pull out your Ace-In-the-Hole. That's the experience card.
Computers still operate on the premise "Garbage IN. Garbage OUT."

It is seriously flawed in some cases but it's what we're given to work with, isn't it? I don't advocate NOT following SOPs but I do advocate some sort of crisis intervention on the part of the experienced crewmember. Even if the action is preceeded with the phrase "non standard" for whatever action out of expedience.

B738

(good little aeroplane the NG)
You are spot on with regard to the SPS. Holding the AP/SP push button for more than 4 seconds disconnects the pusher.
So much for the deep stall theory. And, thanks for pointing it out.

:ok:

B738

14th Jul 2005, 12:38

@ Willie

B738

(good little aeroplane the NG)

Oh yes, but at the moment I have to fly the CRJ 200 and 700.

kontrolor

25th Aug 2006, 18:08

the way I see it: there are two joung pilots, both eager to join FL410 club, but overstress the aircraft, completely disregard the high AOA and low speed at high level, when they realize their mistake, they don't admit it, but rather try to save their face, all resulting in tragedy. I've seen it in my military flying days.

rhovsquared

25th Aug 2006, 19:00

So many people had to die to make aviation as safe as it is today, TCAS, EGWPS, WXR, Doppler, Stick pushers :eek: and on and on ... the educational value of this accident....IT'S NOT A GAME UP THERE, NEVER!!! :=

" How One Fine Man is Ill-Used by Fate
And Another Dare's To Deceive It"
Ernest K. Gann-Fate is The Hunter

...Then as filed :} ,
rhov :)

filejw

25th Aug 2006, 21:08

Sad thing is if you go back say 30 yrs you will find somebody that has done this before.We seem hell bent to repeat our mistakes .One reason when I was younger I read lots of accident reports,just to make sure i didn't make the same mistake's as others.

rhovsquared

25th Aug 2006, 22:19

filejw...We're back to the original Take-Off and Landing accidents...:(
who knows we may one day advance back to Aluminum showers :\

Always Follow TCAS :},
rhov :)

Ignition Override

26th Aug 2006, 04:16

W. Everlearn:
(It looks like you have) I jumpseated last month on the CRJ-my first time, and liked the c0ckpit. Remember comments that the plane has no autothrottles. On the EPR gauges, do they not always indicate with pointers which EPR is required in takeoff, climb, cruise, ga etc, as with the 757 and many others?

I felt it might be misunderstood to enquire about the accident while on the jumpseat: the guys who flew me were really tired, as always, and on the last leg of a long trip with about five legs per day, maybe more on some.
So, with the accident crew, should the EPR indicators have displayed higher power settings than the engines could produce for FL 410 etc? Or was there, generally speaking, a small, subtle message on the EICAS screen which warned about a minimum airspeed for such an extreme altitude, based on the ram air temp, assumed weight etc, or any other readable message displayed in either red or amber?

Maybe they should have glanced at a QRH or easy-to-read performance manual (it can be forgotten), as we do now and then, to know if a heavy plane can slow to 250-260 KIAS as requested by ATC?

Willie Everlearn

26th Aug 2006, 14:03

Ignition Override
First of all, this or any other airline crew, as you've suggested, should have looked at the "chart" to see if they could make the intended change in altitude. Perhaps this crew did, I wouldn't know. According to the "chart" this aircraft was capable of FL410 if it was flown as it should have been flown. It wasn't. They apparently used a zoom climb technique which is simply using airspeed to produce rates of climb to get you there. Unfortunately, at a cost. Airspeed. When they finally reached FL410, they were about M0.54 when they should have flown a constant M0.74. The complication at altitude is acceleration to the required cruise mach. Preferably one above the stall. M0.54 is a stall speed. Thrust is set to the 'carrot' for max CRZ (or MCT, which is likely to match CRZ at this point). Now the dilemma gets realized. At this max power setting you get the thrust the engine is capable of producing at FL410 and that thrust is insufficient to overcome the aerodynamic drag and allow the aircraft to accelerate to point 7 4 out of the stall region.
The CRJ has N1 'carrots' for all Max. power settings (including CRZ) and like it's CF6 lineage, the CF34 displays N1s and N2s separated by the ITTs. So it would be simple and straight forward enough for this crew to see what their maximum cruise N1 setting would be at FL410. The carrots automatically (reduce) adjust as you climb. The difficulty in attaining and maintaining the required cruise speed (M0.74) from the reported M0.54 speed at which they levelled off, would be virtually impossible as it is most probable they were at maximum TLA resulting in maximum CRZ thrust and nowhere near the required Thrust vs Drag to recover. Aerodynamic drag being greater than the actual thrust available from the engine at that altitude. Therefore, stalling was imminent.

Also, at that altitude, lowering the nose would have had to have been gentle rather than abrupt to avoid shaker. Based on the number of reported initial shaker and pusher events noted in the report, they might have been a little aggressive in stall recovery which in turn induced secondary stalls. It's also reported that the aircraft recovered at FL290. A substantial loss of altitude.

I wonder if the recent Tu-154 crash in the Ukraine might have been the result of an aircraft being too high for performance, stalling and entering a flat spin out of control. All in an effort to avoid Thunderstorms.
Willie
:ok: